Information Collection

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

IC 228027 under ICR 202103-0938-008 · OMB 0938-1349.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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 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
CMS-10650 IM Agent Broker Privacy and Security Agreement CMS-10650 - 2017 IM Agent Broker Privacy and Security Agreement.pdf	Form and Instruction

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: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 155.260(b)

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
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

table that charts IC Documents
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.