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

State Permissions for Enrollment in Qualified Health Plans in the Federally Facilitated Exchange & Non-Exchange Entities (CMS-10650)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1349 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10650 ICRs Related to Non-Exchange Entities: Privacy and Security Policies and Procedures (§155.260(b)) Form and Instruction
CMS-10650 Agent Broker Privacy and Security Agreement CMS-10650 - 2017 SHOP Agent Broker Privacy and Security Agreement.pdf Form and Instruction
CMS-10650 IM Agent Broker Privacy and Security Agreement CMS-10650 - 2017 IM Agent Broker Privacy and Security Agreement.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	ICRs Related to Non-Exchange Entities: Privacy and Security Policies and Procedures (§155.260(b))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 155.260(b)

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,335	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,335	3,335
Annual IC Time Burden (Hours)	179,256	179,256
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.