Information Collection

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

IC 183403 under ICR 200801-0938-007 · OMB 0938-1035.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1035 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10220 Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form	Form and Instruction
CMS-10220 CMS-10220 Type 1 - Individual Enrollment Security Consen CMS-10220 Type 1 - Individual Enrollment Security Consent Form 10-2007 .doc	Form and Instruction
CMS-10220 CMS-10220 Type 2 - Organization Enrollment Security Cons CMS-10220 Type 2 - Organization Enrollment Security Consent Form 10-2007.doc	Form and Instruction

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10220	CMS-10220 Type 1 - Individual Enrollment Security Consent Form	CMS-10220 Type 1 - Individual Enrollment Security Consent Form 10-2007 .doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10220	CMS-10220 Type 2 - Organization Enrollment Security Consent Form	CMS-10220 Type 2 - Organization Enrollment Security Consent Form 10-2007.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	5,000	5,000
Annual IC Cost Burden (Dollars)	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.