Information Collection

Agent/Broker Eligibility and Consent Records

IC 259918 under ICR 202304-0938-025 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10840 Agent/Broker Eligibility and Consent Records	Form and Instruction
CMS-10840 Agent Broker Consent Form Appendix_C_CMS-10840_Agent-Broker_Consent_Consent_Form_508.pdf	Form and Instruction
CMS-10840 Agent Broker Consent Form Appendix_C_CMS-10840_Agent-Broker_Consent_Consent_Form_508.pdf	Form and Instruction

IC Title:

Agent/Broker Eligibility and Consent Records

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(j)(2)(iii)

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-10840	Agent Broker Consent Form	Appendix_C_CMS-10840_Agent-Broker_Consent_Consent_Form_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

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: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	16,003	16,003

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.