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Federal forms, ICRs, and supporting documents

Information Collection

155.225(d)(2) and (f) (CAC authorization to consumer)

IC 207940 under ICR 202110-0938-014 · OMB 0938-1205.

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

View Information Collection (IC)

155.225(d)(2) and (f) (CAC authorization to consumer)
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
45 CFR 155.225(d)(2) and (f)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10494 CAC Agreement CMS-10494 - Appendix G_Individual CAC Agreementx.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10494 Model Authorization Form (English) CMS-10494 - Appendix J Model Authorization Form English.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10494 Model Authorization Form (Spanish) CMS-10494 - Appendix K_Model Authorization Form Spanish.docx Yes Yes Fillable Fileable

Health Health Care Services

 

30,000 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   80 %

  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 2,200,000 0 0 0 0 2,200,000
Annual IC Time Burden (Hours) 585,200 0 0 0 0 585,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.