Information Collection

Certified Counselor Designated Organization (CDO Application)

IC 241050 under ICR 201810-0938-013 · OMB 0938-1205.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1205 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10494 Certified Counselor Designated Organization (CDO Application) Form and Instruction
CMS-10494 - Appendix G_CDO-CAC Model Agreement.pdf Instruction
CMS-10494 CDO Agreement CMS-10494 - Appendix B_CMS-CDO Agreement.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certified Counselor Designated Organization (CDO Application)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155225(b)(1)(iii) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	CDO Agreement	CMS-10494 - Appendix B_CMS-CDO Agreement.pdf		Yes	Yes	Fillable Fileable
Instruction			CMS-10494 - Appendix G_CDO-CAC Model Agreement.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	7,000	7,000
Annual IC Time Burden (Hours)	1,225	1,225
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.