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Federal forms, ICRs, and supporting documents

Information Collection

ICRs Related to Non-Exchange Entities: Privacy and Security Policies and Procedures (§155.260(b))

IC 228027 under ICR 201708-0938-021 · OMB 0938-1349.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

ICRs Related to Non-Exchange Entities: Privacy and Security Policies and Procedures (§155.260(b))
 
No New
 
Required to Obtain or Retain Benefits
 
42 CFR 155.260(b)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10650 Agent Broker Privacy and Security Agreement CMS-10650 - 2017 SHOP Agent Broker Privacy and Security Agreement.pdf Yes Yes Paper Only
Form and Instruction CMS-10650 IM Agent Broker Privacy and Security Agreement CMS-10650 - 2017 IM Agent Broker Privacy and Security Agreement.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

3,335 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 3,335 3,335 0 0 0 0
Annual IC Time Burden (Hours) 179,256 179,256 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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