Information Collection

Agent/Broker Eligibility and Consent Records

IC 259918 under ICR 202602-0938-011 · OMB 0938-1438.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10840 Agent Broker Consent Form Agent/Broker Eligibility and Consent Records	Form and Instruction
CMS-10840 Agent Broker Consent Form CMS-10840 - Appendix A Model Consent Form.docx	Form and Instruction

IC Title:

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(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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	34,080	34,080

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].