Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS 10209-CCIP Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project Form and Instruction
CMS 10209-CCIP Chronic Care Improvement Program Reporting Template #3.CCIP ReportingTemplate .docx Form and Instruction
CMS 102-QIP Medicare Advantage Quality Improvement Project Reporting #3.QIP Reporting Template.docx Form and Instruction
#3. TA Survey.docx #3 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.152a 42 CFR 422.152(a)(1) and (2)

Information Collection 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	#3.CCIP ReportingTemplate .docx		Yes	Yes	Paper Only
Form and Instruction	CMS 102-QIP	Medicare Advantage Quality Improvement Project Reporting Template	#3.QIP Reporting Template.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 394	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	788	-64	852
Annual IC Time Burden (Hours)	18,912	9,685	9,227
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
#3	#3. TA Survey.docx	07/09/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.