PECOS Web Security Consent Form - Individuals

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1035 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10220 PECOS Web Security Consent Form - Individuals Form and Instruction
CMS-10220 Security Consent and Surrogate Authorization Form Security Consent and Surrogate Authorization Form100113.docx Form and Instruction

Information Collection (IC) Details

IC Title:	PECOS Web Security Consent Form - Individuals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10220	Security Consent and Surrogate Authorization Form	Security Consent and Surrogate Authorization Form100113.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	52,500	-105,000	157,500
Annual IC Time Burden (Hours)	13,125	-26,250	39,375
Annual IC Cost Burden (Dollars)	0	0	0

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.