Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form (CMS-10220)

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 can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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All Historical Document Collections

201705-0938-010 Approved with change	Reinstatement with change of a previously approved collection	2017-05-24
201311-0938-007 Approved without change	Reinstatement with change of a previously approved collection	2013-11-08
200801-0938-007 Approved without change	New collection (Request for a new OMB Control Number)	2008-01-15

OMB Details

PECOS Web Security Consent Form - Individuals

Federal Enterprise Architecture: Health - Health Care Services

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.