Information Collection

Business Associate Privacy Agreement

IC 226553 under ICR 202008-0938-012 · OMB 0938-1011.

Documents and Forms

Document Name Document Type
Form CMS-10199 Business Associate Privacy Agreement Form and Instruction
CMS-10199 BUSINESS ASSOCIATE AGREEMENT CAS_Business-Associate-Agreement 2020.pdf Form and Instruction
CMS-10199 BUSINESS ASSOCIATE AGREEMENT CAS_Business-Associate-Agreement 2020.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Business Associate Privacy Agreement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10199	BUSINESS ASSOCIATE AGREEMENT	CAS_Business-Associate-Agreement 2020.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,420	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: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,420	50	1,370
Annual IC Time Burden (Hours)	237	9	228
Annual IC Cost Burden (Dollars)	0	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.