Information Collection Request

Supporting Statement for Agent/Broker Consent Information Collection (CMS-10840)

ICR 202304-0938-025 · OMB 0938-1438 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1438 can be found here:

Forms and Documents

Document Name	Status
Form CMS-10840 Agent/Broker Eligibility and Consent Records Form and Instruction	New
Form CMS-10840 Agent/Broker Eligibility and Consent Documentation Form	Modified
Appendix_A_CMS-10840_Agent-Broker_Consent_60-Day_Comment_Response_508.pdf Supplementary Document	2023-04-27
CMS-10840_Agent-Broker Consent_Supporting Statement.docx Supporting Statement A	2023-04-27

IC Document Collections

IC ID	Document Title	Status
259918	Agent/Broker Eligibility and Consent Records Form and Instruction	New
257714	Agent/Broker Eligibility and Consent Documentation Form	Modified

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1438
Type of Information Collection	New collection (Request for a new OMB Control Number)
Previous ICR Reference No	202301-0938-001
Agency Tracking No	CCIIO
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31