Information Collection

Medicare EDI Enrollment Form and EDI Registration

IC 8845 under ICR 202602-0938-017 · OMB 0938-0983.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10164 A CMS EDI Enrollment Registration Form Medicare EDI Enrollment Form and EDI Registration	Form and Instruction
Form CMS-10164 B CMS EDI Enrollment Agreement Form Medicare EDI Enrollment Form and EDI Registration	Form and Instruction
Form CMS-10164 C CMS-EDI Enrollment Attestation Form Medicare EDI Enrollment Form and EDI Registration	Form and Instruction
CMS-10164 A CMS EDI Enrollment Registration Form 10164A_CMS-EDI-Registration-Form.pdf	Form and Instruction
CMS-10164 B CMS EDI Enrollment Agreement Form 10164B_CMS EDI Enrollment Agreement Form.pdf	Form and Instruction
CMS-10164 C CMS-EDI Enrollment Attestation Form 10164C_CMS-EDI-Enrollment-Attestation-Form.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

OIT

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 162

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10164 A	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10164 B	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10164 C	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 229,767

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	229,767	-951,442	1,181,209
Annual IC Time Burden (Hours)	153,178	-240,558	393,736
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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