Information Collection

Agent/Broker Consent

IC 257714 under ICR 202301-0938-001 · OMB 0938-1438.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1438 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10840 Agent/Broker Consent Form
CMS-10840 CMS Model Consent Form for Marketplace Agents and Broker CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf Form
CMS-10840 CMS Model Consent Form for Marketplace Agents and Broker CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Agent/Broker Consent	Agency IC Tracking Number:	CCIIO - 10840

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.220

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10840	CMS Model Consent Form for Marketplace Agents and Brokers	CMS-10840_Agent-Broker_Consent_Appenidx_A_Consent_Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,630,899	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	3,630,899	3,630,899
Annual IC Time Burden (Hours)	290,568	290,568
Annual IC Cost Burden (Dollars)	19,352,692	19,352,692

Documents for IC

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.