Form CMS-10464 Agent-Broker Appendix A Screenshot_508_07.20.22

OMB Control # 0938-1204
Expiration Date: xx/xx/2022
AB PRA Screenshots
Image 1
CMS Enterprise Portal Login Page

Image 2
Portal new user account information page example

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1204, expiration
date is XX/XX/20XX. The time required to complete this information collection is estimated to take 24 minutes for new agent/
brokers issuers and 12 minutes for returning agent/brokers per response, including the time to complete the Federallyfacilitated Exchange (FFE) registration and training. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

Image 3
Identity Proofing Page Example. Agent Broker completes remote identity proofing within enterprise
Portal.

2

Image 4
Out-of-Wallet Questions Page Example. Agent Broker is asked questions to verify their identity based on
information provided on Identity Proofing page example (see: Image 3).

3

Image 5
Both an Individual and SHOP Marketplace Agent Broker Page Example