Information Collection

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

IC 207940 under ICR 202210-0938-013 · OMB 0938-1205.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10494 155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction
Form CMS-10494 CAC Agreement 155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction
Form CMS-10494 Model Authorization Form (English) 155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction
Form CMS-10494 Model Authorization Form (Spanish) 155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction
CMS-10494 CAC Agreement CMS-10494 - Appendix G_Individual CAC Agreementx.docx	Form and Instruction
CMS-10494 CAC Agreement CMS-10494 - Appendix G_Individual CAC Agreementx.docx	Form and Instruction
CMS-10494 Model Authorization Form (English) CMS-10494 - Appendix J Model Authorization Form English.docx	Form and Instruction
CMS-10494 Model Authorization Form (English) CMS-10494 - Appendix J Model Authorization Form English.docx	Form and Instruction
CMS-10494 Model Authorization Form (Spanish) CMS-10494 - Appendix K_Model Authorization Form Spanish.docx	Form and Instruction
CMS-10494 Model Authorization Form (Spanish) CMS-10494 - Appendix K_Model Authorization Form Spanish.docx	Form and Instruction

IC Title:

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 155.225(d)(2) and (f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,200,000	2,200,000
Annual IC Time Burden (Hours)	585,200	585,200
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.