EFIO name
A blank in the opening paragraph for the name of the organization whose authorized official(s) sign, which the form then calls the electronic file interchange organization, or EFIO.
CMS-10175
Electronic File Interchange Organization (EFIO) Certification Statement
- Agency
- CMS
- Revision
- 03/22
- Fillable fields
- 8
- Pages
- 3
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10175: Electronic File Interchange Organization (EFIO) Certification Statement
Form CMS-10175 is the Electronic File Interchange Organization (EFIO) Certification Statement from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. By signing it, the authorized official of an EFIO legally binds the organization to 13 conditions for submitting information, including National Provider Identifier (NPI) applications, to CMS or its agent on behalf of providers. The form calls CMS or its agent the Enumerator.
The conditions cover the EFIO's written legal authority to act for each provider, how old the submitted data can be, telling providers about a newly issued NPI or a confirmed change, keeping records for 7 years unless CMS prescribes a shorter period, cooperating with verification requests and CMS audits, and the official's own authority to bind the EFIO. The last page holds a federal law warning and the signature block.
The signer is an authorized official who certifies being a W-2 employee and/or owner of the EFIO. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-10175
Conditions 1 to 5: authority and data
Written legal authority to act for each provider, data no more than 12 months old from the date the provider certifies it, prompt notice to providers of a new NPI, a rejection or a confirmed change, and each provider's written confirmation that its information is accurate.
Conditions 6 to 8: licensing, records and verification
State business licensure where a State requires it, keeping provider correspondence and electronic files for 7 years unless CMS prescribes a shorter period, keeping them from unauthorized access, and cooperating with the Enumerator's verification requests.
Conditions 9 to 13: documents, audits and accuracy
The Enumerator's right to ask for more documentation, procedures for handling provider questions, CMS audits of records, the official's authority, and truthful information, with any error reported to the Enumerator immediately.
Federal law warning
A notice citing 18 U.S.C. Section 1001 on fines and/or imprisonment for false statements, followed by a statement that the data are true and correct and that the EFIO's governing body authorized the signature.
Signature block
The first authorized official's full name, title or position and telephone number, the EFIO's legal business name, doing business as name and business address, and the official's signature.
How to fill out Form CMS-10175
- 1
Enter the EFIO's name
Write the organization's name in the blank in the opening paragraph on page 1.
- 2
Read all 13 conditions
The form says the signature legally binds the EFIO to full adherence to every condition on pages 1 and 2.
- 3
Read the federal law notice
Page 3 opens with a notice to read the provision of federal law carefully before signing.
- 4
Fill in the official and business details
Enter the first authorized official's full name, title or position and telephone number, plus the EFIO's legal business name, doing business as name and business address.
- 5
Sign as the first authorized official
The first authorized official signs on page 3, confirming that the governing body of the EFIO has authorized the signature.
Why fill Form CMS-10175 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Sending the form and what it says
Where to send it
The form and the CMS page do not print a mailing address. The CMS address in the Paperwork Reduction Act notice is given for comments on the time estimate or suggestions for improving the form.
Data age
Condition 2 says data the EFIO submits for a provider will be no more than 12 months old from the date the provider certifies its accuracy.
Record keeping
Condition 7 says the EFIO keeps records of provider correspondence and the files it exchanges with the Enumerator for 7 years, unless CMS prescribes a shorter period.
Audits
Condition 11 says CMS reserves the right to examine the records, files and agreements covered by the statement at any time for any reason related to the EFIO's NPI data submissions.
OMB number and dates
The Paperwork Reduction Act notice gives OMB control number 0938-0984, and the top of the form prints an expiration of 03/2025. The CMS page lists a revision date of 2022-02-28 and an O.M.B. expiration date of 2028-12-30.
Time to complete
The form estimates 3 hours per response, including reviewing instructions, gathering the data and completing the form.
Related forms
CMS-855I
Medicare Enrollment Application - Physicians and Non-Physician Practitioners
513 fields, 26 pages
CMS-855B
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
960 fields, 54 pages
CMS-855A
Medicare Enrollment Application - Institutional Providers
1,236 fields, 72 pages
CMS-855O
Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
174 fields, 11 pages
CMS-855S
Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
1,031 fields, 39 pages
Who uses Form CMS-10175?
The form is signed for an organization that submits NPI data on behalf of providers.
Official sources and the blank
Do it all with indox
No tool matches that search.
Questions about Form CMS-10175
What is an EFIO?
The form calls the organization whose authorized officials sign it the electronic file interchange organization, or EFIO. It submits information, including NPI applications, to CMS or its agent, which the form calls the Enumerator, on behalf of providers.
Who signs Form CMS-10175?
An authorized official of the EFIO. The form says the signer certifies having the legal authority to bind the EFIO and being a W-2 employee and/or owner of the EFIO.
How old can the provider data be?
The form says data the EFIO submits on a provider's behalf will be no more than 12 months old from the date the provider certifies its accuracy.
How long does the EFIO keep records?
Condition 7 says 7 years, unless CMS prescribes a shorter period. It covers correspondence with providers and the electronic files exchanged with the Enumerator.
Can CMS audit the EFIO's records?
Condition 11 says CMS reserves the right to examine those records at any time for any reason related to the EFIO's NPI data submissions, and the EFIO certifies it will fully cooperate.
How long does the form take to complete?
The Paperwork Reduction Act notice estimates 3 hours per response.