Information Collection

Certified Counselor Designated Organization (CDO Application)

IC 241050 under ICR 202110-0938-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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 - Appendix G_CDO-CAC Model Agreement.pdf	Instruction
CMS-10494 CDO Agreement CMS-10494 - Appendix B_CMS-CDO Agreement.pdf	Form and Instruction
CMS-10494 CDO Agreement CMS-10494 - Appendix B_CMS-CDO Agreement.pdf	Form and Instruction

IC Title:

Certified Counselor Designated Organization (CDO Application)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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:

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-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 %

table that charts list of burden
	Approved	Previously Approved
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

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.