Information Collection

Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

IC 179877 under ICR 200704-0938-012 · OMB 0938-1023.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1023 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10209 CCIP Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project	Form and Instruction
CMS-10209 QIP Medicare Advantage Quality Improvement Project Reporting QIP Reporting Template 02-05-07 .doc	Form and Instruction
CMS-10209 CCIP Chronic Care Improvement Program Reporting Template CCIP ReportingTemplate 02-05-07.doc	Form and Instruction

IC Title:

Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.152a

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10209 CCIP	Chronic Care Improvement Program Reporting Template	CCIP ReportingTemplate 02-05-07.doc		Yes	Yes	Paper Only
Form and Instruction	CMS-10209 QIP	Medicare Advantage Quality Improvement Project Reporting	QIP Reporting Template 02-05-07 .doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 426

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	852	852
Annual IC Time Burden (Hours)	9,227	9,227
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.