Information Collection

Agents/Broker Data Collection in Federally Facilitated Health Insurance Exchanges

IC 207074 under ICR 202511-0938-013 · OMB 0938-1204.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10464 Agents/Broker Data Collection in Federally Facilitated Health Insurance Exchanges	Form and Instruction
Form CMS-10464 Agent-Broker Appendix A Screenshot Agents/Broker Data Collection in Federally Facilitated Health Insurance Exchanges	Form and Instruction
CMS-10464 Agent-Broker Appendix A Screenshot CMS-10464 - Appendix - A - Screenshots.pdf	Form and Instruction
CMS-10464 Agent-Broker Appendix A Screenshot CMS-10464 - Appendix - A - Screenshots.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

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:

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-10464				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	100,000	36,000	64,000
Annual IC Time Burden (Hours)	12,000	-3,360	15,360
Annual IC Cost Burden (Dollars)	0	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.

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