Information Collection

Medicare EDI Enrollment Form and EDI Registration

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare EDI Enrollment Form and EDI Registration	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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10164 A	CMS EDI Enrollment Registration Form	10164A_CMS-EDI-Registration-Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10164 B	CMS EDI Enrollment Agreement Form	10164B_CMS EDI Enrollment Agreement Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10164 C	CMS-EDI Enrollment Attestation Form	10164C_CMS-EDI-Enrollment-Attestation-Form.pdf	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 %

	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

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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