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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.