PCIP Authorization Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1161 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10428 PCIP Authorization Form Form and Instruction
CMS-10428 Pre-Existing Condition Insurance Plan (PCIP) HIPAA Autho PCIP HIPAA Authorization Form (FINAL).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	PCIP Authorization Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 164.508

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	2,100	2,100
Annual IC Time Burden (Hours)	525	525
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.