Information Collection

Agent/Broker Eligibility and Consent Documentation

IC 257714 under ICR 202501-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Documentation Form
CMS-10840 CMS Model Consent Form Appendix A - Model Consent Form_2026.docx Form
CMS-10840 CMS Model Consent Form Appendix A - Model Consent Form_2026.docx Form

Information Collection (IC) Details

View Information Collection (IC)

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

Is this a Common Form? No		IC Status: Modified

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	Appendix A - Model Consent Form_2026.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,800,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,800,000	4,852,091	4,947,909
Annual IC Time Burden (Hours)	1,666,001	824,856	841,145
Annual IC Cost Burden (Dollars)	52,234,000	25,861,645	26,372,355

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.