Information Collection

Security Consent and Surrogate Authorization Form - Providers

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Security Consent and Surrogate Authorization Form - Providers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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 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 %

	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

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.