155.225(d)(2) and (f) (CAC authorization to consumer)

Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel -CAC (CMS-10494)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1205 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10494 155.225(d)(2) and (f) (CAC authorization to consumer) Form and Instruction
CMS-10494 CAC Agreement CMS-10494 - Appendix G_Individual CAC Agreement.pdf Form and Instruction
CMS-10494 Model Authorization Form (English) CMS-10494 - Appendix J Model Authorization Form English.pdf Form and Instruction
CMS-10494 Model Authorization Form (Spanish) CMS-10494 - Appendix K_Model Authorization Form Spanish.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	155.225(d)(2) and (f) (CAC authorization to consumer)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.225(d)(2) and (f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	CAC Agreement	CMS-10494 - Appendix G_Individual CAC Agreement.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10494	Model Authorization Form (English)	CMS-10494 - Appendix J Model Authorization Form English.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10494	Model Authorization Form (Spanish)	CMS-10494 - Appendix K_Model Authorization Form 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: 30,000	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: 80 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,200,000	2,200,000
Annual IC Time Burden (Hours)	585,200	585,200
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.