Information Collection

PECOS Web Security Consent Form - Individuals

IC 183402 under ICR 201705-0938-010 · OMB 0938-1035.

Documents and Forms

Document Name Document Type
Form CMS-10220 PECOS Web Security Consent Form - Individuals 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

View Information Collection (IC)

IC Title:	PECOS Web Security Consent Form - Individuals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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: 52,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-52,500	52,500
Annual IC Time Burden (Hours)	-13,125	13,125
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.