Information Collection

Consumer authorization forms

IC 216292 under ICR 201504-0938-014 · OMB 0938-1220.

Documents and Forms

Document Name Document Type
Form CMS-10472 Consumer authorization forms Form and Instruction
CMS-10472 Model Authorization Form (Navigators) Appendix D_Model Authorization Form for Navigators.pdf Form and Instruction
CMS-10472 Model Aurthorization Form - (Navigators - Spanish) Appendix E_ Model Authorization Form-Navigators_Spanish.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Consumer authorization forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.210

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10472	Model Authorization Form (Navigators)	Appendix D_Model Authorization Form for Navigators.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10472	Model Aurthorization Form - (Navigators - Spanish)	Appendix E_ Model Authorization Form-Navigators_Spanish.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,610	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	5,610	5,610
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	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.