Information Collection

PCIP Authorization Form

IC 201588 under ICR 201304-0938-003 · OMB 0938-1161.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10428 PCIP Authorization Form	Form
CMS-10428 Pre-Existing Condition Insurance Plan (PCIP) HIPAA Autho PCIP_HIPAA_AuthorizationForm_508wPRA-a.pdf	Form

IC Title:

PCIP Authorization Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 164.508

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	CMS-10428	Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form	PCIP_HIPAA_AuthorizationForm_508wPRA-a.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 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
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

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.