PCIP Authorization Form

Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form

OMB: 0938-1161

IC ID: 201588

Information Collection (IC) Details

View Information Collection (IC)

PCIP Authorization Form
 
No New
 
Voluntary
 
45 CFR 164.508

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10428 Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form PCIP HIPAA Authorization Form (FINAL).pdf Yes No Fillable Fileable

Health Health Care Services

 

2,100 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,100 2,100 0 0 0 0
Annual IC Time Burden (Hours) 525 525 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 OMB.report | Privacy Policy