PECOS Web Security Consent Form - Organizations

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10220 PECOS Web Security Consent Form - Organizations Form and Instruction
CMS-10220 Security Consent and Surrogate Authorization Form Security Consent and Surrogate Authorization Form100113.docx Form and Instruction

Information Collection (IC) Details

IC Title:	PECOS Web Security Consent Form - Organizations	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:

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: 36,150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	36,150	16,150	20,000
Annual IC Time Burden (Hours)	9,038	4,038	5,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.