PECOS Web Security Consent Form - Organizations

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

OMB: 0938-1035

IC ID: 183403

Information Collection (IC) Details

View Information Collection (IC)

PECOS Web Security Consent Form - Organizations
 
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

 

36,150 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 36,150 0 0 16,150 20,000 0
Annual IC Time Burden (Hours) 9,038 0 0 4,038 5,000 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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