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

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

OMB: 0938-1205

IC ID: 207940

Information Collection (IC) Details

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155.225(d)(2) and (f) (CAC authorization to consumer)
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR 155.225(d)(2) and (f)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10494 CAC Agreement CMS-10494 - Appendix G_Individual CAC Agreementx.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10494 Model Authorization Form (English) CMS-10494 - Appendix J Model Authorization Form English.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10494 Model Authorization Form (Spanish) CMS-10494 - Appendix K_Model Authorization Form Spanish.docx Yes Yes Fillable Fileable

Health Health Care Services

 

30,000 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   80 %

  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 2,200,000 0 0 0 0 2,200,000
Annual IC Time Burden (Hours) 585,200 0 0 0 0 585,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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