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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.