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Crosswalk document - Securuty Consent Form
ICR 201705-0938-010 · OMB 0938-1035 · Object 74125001.
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| CMS-10220 - RESECTIONING & REVISION MAPPING GUIDE | ||||
| Current Section Location | Current Section Header (OMB form approved 02/14) | New Section Location | New Section Header | Revisions |
| Title | SECURITY CONSENT AND SURROGATE AUTHORIZATION FORM | Title | SECURITY CONSENT AND SURROGATE AUTHORIZATION FORM | Header, right side: add Expiration Date |
| 1 | Security Consent and Surrogate Authorization Form Purpose and Definitions | n/a | Instructions for Completing the Security Consent and Surrogate Authorization Form | Add Note at the end of Instructions in bold: NOTE: LACK OF PROPER DOCUMENTATION (e.g., Government Issued identification for individuals and Internal Revenue Service (IRS) CP-575 (or equivalent) WILL RESULT IN A REJECTION OF THIS REQUEST. |
| 2 | Confirmation of Understanding and Penalties for Falsifying Information for Individual or Organizational Provider | n/a | Examples | |
| 3A | Individual Provider | 1 | Security Consent and Surrogate Authorization Form Purpose and Definitions | |
| 3B | Organizational Provider | 2 | Confirmation of Understanding and Penalties for Falsifying Information for Individual or Organizational Provider | Add Note at the end of Section 2 in bold: NOTE: LACK OF PROPER DOCUMENTATION (e.g., Government Issued identification for individuals and Internal Revenue Service (IRS) CP-575 (or equivalent) WILL RESULT IN A REJECTION OF THIS REQUEST. |
| 4 | CMS Computer Systems | 3A | Individual Provider | |
| 5A | Surrogate Organization | 3B | Organizational Provider | |
| 5B | Surrogate Individual | 4 | CMS Computer Systems | |
| n/a | Instructions for Completing the Security Consent and Surrogate Authorization Form | 5A | Surrogate Organization | |
| n/a | Examples | 5B | Surrogate Individual | |
| 6 | Required Documentation and Submission Instructions | Added section 6 per NPPES |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Title | Crosswalk document - Securuty Consent Form |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |