Information Collection

PECOS Web Security Consent Form - Individuals

IC 183402 under ICR 201311-0938-007 · OMB 0938-1035.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1035 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10220 PECOS Web Security Consent Form - Individuals	Form and Instruction
CMS-10220 Security Consent and Surrogate Authorization Form Security Consent and Surrogate Authorization Form100113.docx	Form and Instruction

IC Title:

PECOS Web Security Consent Form - Individuals

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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 and Instruction	CMS-10220	Security Consent and Surrogate Authorization Form	Security Consent and Surrogate Authorization Form100113.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	52,500	-105,000	157,500
Annual IC Time Burden (Hours)	13,125	-26,250	39,375
Annual IC Cost Burden (Dollars)	0	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.