Information Collection

Consumer authorization forms

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

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-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 %

table that charts list of burden
	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

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.