OMB control number
Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form (CMS-10220)
OMB 0938-1035 · HHS/CMS.
OMB 0938-1035
The Security Consent and Surrogate Authorization form replicates business service agreements between Medicare providers/suppliers and Surrogates providing enrollment services. We are proposing one version of the Security Consent and Surrogate Authorization Form. The form, once signed, mailed and approved, grants a Surrogate access to all current and future enrollment data for the Individual or Organization Provider.
The latest form for Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form (CMS-10220) expires 2020-12-31 and is listed under ICR 201705-0938-010.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10220 Security Consent and Surrogate Authorization Form - Providers | Form and Instruction |
| Form CMS-10220 PECOS Web Security Consent Form - Organizations | Form and Instruction |
| Form CMS-10220 PECOS Web Security Consent Form - Individuals | Form and Instruction |
 CMS-10220 - Crosswalk.xlsx | Supplementary Document |
| CMS-10220 - Supporting Statement PECOS Final.docx | Supporting Statement A |
 Security Consent and Surrogate Authorization Form - Providers |
Form and Instruction |
| PECOS Web Security Consent Form - Organizations |
Form and Instruction |
| PECOS Web Security Consent Form - Individuals |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 201705-0938-010 | Reinstatement with change of a previously approved collection | 2017-05-24 | Approved with change | |
| 201311-0938-007 | Reinstatement with change of a previously approved collection | 2013-11-08 | Approved without change | |
| 200801-0938-007 | New collection (Request for a new OMB Control Number) | 2008-01-15 | Approved without change |
OMB Details
PECOS Web Security Consent Form - Individuals
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form CMS-10220 | Security Consent and Surrogate Authorization Form | Fillable Fileable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.