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

Forms and Documents

Document Name	Status
Form CMS-10428 PCIP Authorization Form Form and Instruction	Modified
Justification of Non-material change.docx Justification for No Material/Nonsubstantive Change	2013-06-18

IC Document Collections

IC ID	Document Title	Status
201588	PCIP Authorization Form Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1161	ICR Reference No: 201306-0938-009
Status: Historical Active	Previous ICR Reference No: 201304-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: 19816
Title: Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/28/2013
	Date Received in OIRA: 06/18/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	05/31/2016	05/31/2016
Responses	2,100	0	2,100
Time Burden (Hours)	525	0	525
Cost Burden (Dollars)	0	0	0

---

Abstract: Due to their health conditions, some PCIP applicants and enrollees require assistance from a third party when making inquiries to the PCIP program. Under the Health Insurance Portability and Accountability Act (HIPAA), the PCIP program may not disclose information about an applicant or enrollee to a third party without a valid authorization. The PCIP authorization form will allow a PCIP applicant or enrollee to designate an individual or organization to contact PCIP on behalf of the applicant or enrollee. This will make it easier for PCIP applicants and enrollees to obtain information and resolve issues regarding the application process, premium payments, claims status, and other matters.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1101 Name of Law: Temporary High Risk Health Insurance Pool Program
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
PCIP Authorization Form	CMS-10428	PCIP Authorization Form

---

ICR Summary of Burden

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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $20

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/18/2013

---