PECOS Web Security Consent Form - Individuals

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

OMB: 0938-1035

IC ID: 183402

Information Collection (IC) Details

View Information Collection (IC)

PECOS Web Security Consent Form - Individuals
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10220 Security Consent and Surrogate Authorization Form Security Consent and Surrogate Authorization Form100113.docx Yes No Fillable Fileable

Health Health Care Services

 

52,500 0
   
Individuals or Households
 
   100 %

  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 52,500 0 0 -105,000 157,500 0
Annual IC Time Burden (Hours) 13,125 0 0 -26,250 39,375 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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