Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10220 CMS-10220 Type 2 - Organization Enrollment Security Consent Form	Form and Instruction	New	Available
Form CMS-10220 CMS-10220 Type 1 - Individual Enrollment Security Consent Form	Form and Instruction	New	Available
Form CMS-10220 Individual Enrollment Security Consent Form	Form and Instruction	New	Available
Form CMS-10220 Organization Enrollment Security Consent Form	Form and Instruction	New	Available
CMS-10220 Response to OMB Comments 02152008.doc	Supplementary Document	Uploaded 2008-02-19	Available
CMS-10220 Response to Public Comments.doc	Supplementary Document	Uploaded 2007-11-05	Available
CMS-10220.Supporting Statement Security Consent Form-11-21-2007.doc	Supporting Statement A	Uploaded 2007-11-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
183403	Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form	Form and Instruction	New	CMS-10220 Type 2 - Organization Enrollment Security Consent Form
183403	Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form	Form and Instruction	New	CMS-10220 Type 1 - Individual Enrollment Security Consent Form
183402	Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form	Form and Instruction	New	Individual Enrollment Security Consent Form
183402	Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form	Form and Instruction	New	Organization Enrollment Security Consent Form

ICR Details

OMB Control No: 0938-1035	ICR Reference No: 200801-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/22/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/15/2008
Terms of Clearance: CMS will update the burden and number of responses as appropriate.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	36 Months From Approved
Responses	177,500	0	0
Time Burden (Hours)	44,375	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The security consent form replicates business service agreements between Medicare applicants and organizations providing enrollment services. The purpose of this form is to grant a User group (e.g. a group of one or more individuals completing enrollments on behalf of Medicare applicants) access to all current and future enrollment data for the Medicare provider.

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Authorizing Statute(s): US Code: 42 USC 1395g(a) Name of Law: PAYMENT TO PROVIDERS OF SERVICES
   US Code: 42 USC 1395l(e) Name of Law: PAYMENT OF BENEFITS
   US Code: 42 USC 1395m(j) Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395f(a) Name of Law: CONDITIONS OF AND LIMITATIONS ON PAYMENT FOR SERVICES
   US Code: 42 USC 1395u(u) Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395u(r) Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395cc(j)(1)(C) Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   PL: Pub.L. 105 - 33 4313 Name of Law: The Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 13792	03/23/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 63611	11/09/2007
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form	CMS-10220, CMS-10220	CMS-10220 Type 1 - Individual Enrollment Security Consent Form ,   CMS-10220 Type 2 - Organization Enrollment Security Consent Form
Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form	CMS-10220, CMS-10220	Organization Enrollment Security Consent Form ,   Individual Enrollment Security Consent Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	177,500	0	0	177,500	0	0
Annual Time Burden (Hours)	44,375	0	0	44,375	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/15/2008

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