Information Collection

Agent/Broker Eligibility and Consent Documentation

IC 257714 under ICR 202602-0938-011 · OMB 0938-1438.

Documents and Forms

Document Name Document Type
Form CMS-10840 CMS Model Consent Form Agent/Broker Eligibility and Consent Documentation Form
CMS-10840 CMS Model Consent Form CMS-10840 - Appendix A Model Consent Form.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	CMS-10840 - Appendix A Model Consent Form.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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	9,800,000	0	9,800,000
Annual IC Time Burden (Hours)	1,666,000	-1	1,666,001
Annual IC Cost Burden (Dollars)	52,234,000	0	52,234,000

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.

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