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

Forms and Documents

Document Name	Status
Form CMS-10220 PECOS Web Security Consent Form - Organizations Form and Instruction	Modified
Form CMS-10220 PECOS Web Security Consent Form - Individuals Form and Instruction	Modified
Response to Public Comment.docx Supplementary Document	2013-11-06
SCF - Revisions Crosswalk - 10012013.doc Supplementary Document	2013-11-06
CMS-10220_Supporting_Statement_Part_A.docx Supporting Statement A	2013-11-06

IC Document Collections

IC ID	Document Title	Status
183403	PECOS Web Security Consent Form - Organizations Form and Instruction	Modified
183402	PECOS Web Security Consent Form - Individuals Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1035	ICR Reference No: 201311-0938-007
Status: Historical Active	Previous ICR Reference No: 200801-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: 20872
Title: Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/14/2014
	Date Received in OIRA: 11/08/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	88,650	0	0
Time Burden (Hours)	22,163	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 42 USC 1395f(a) Name of Law: CONDITIONS OF AND LIMITATIONS ON PAYMENT FOR SERVICES
   US Code: 42 USC 1395g(a) Name of Law: PAYMENT TO PROVIDERS OF SERVICES
   US Code: 42 USC 1395l(e) Name of Law: PAYMENT OF BENEFITS
   US Code: 42 USC 1395m(j) Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395u(u) Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395u(r) Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395cc(j)(1)(C) Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   PL: Pub.L. 105 - 33 4313 Name of Law: The Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 34387	06/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 65658	11/01/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
PECOS Web Security Consent Form - Individuals	CMS-10220	Security Consent and Surrogate Authorization Form
PECOS Web Security Consent Form - Organizations	CMS-10220	Security Consent and Surrogate Authorization Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	88,650	0	0	0	-88,850	177,500
Annual Time Burden (Hours)	22,163	0	0	0	-22,212	44,375
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden has been adjusted and the form has been condensed from two forms into one.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/08/2013

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