Information Collection

Security Consent and Surrogate Authorization Form - Providers

IC 226985 under ICR 201705-0938-010 · OMB 0938-1035.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10220 Security Consent and Surrogate Authorization Form - Providers	Form and Instruction
CMS-10220 Security Consent Form CMS-10220 -Security Consent Form 05152017.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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-10220	Security Consent Form	CMS-10220 -Security Consent Form 05152017.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 226,100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	226,100	226,100
Annual IC Time Burden (Hours)	226,100	226,100
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.