Information Collection

QualityNet Identity Management System (QIMS) Account Form (First Year)

IC 186126 under ICR 201010-0938-003 · OMB 0938-1050.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1050 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10267 QualityNet Identity Management System (QIMS) Account Form (First Year) Form and Instruction
CMS-10267 CMS-10267.QIMS- Account Registration Form CMS-10267.QIMS- Account Registration Form final4.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	QualityNet Identity Management System (QIMS) Account Form (First Year)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10267	CMS-10267.QIMS- Account Registration Form	CMS-10267.QIMS- Account Registration Form final4.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,439	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	7,439	-5,561	13,000
Annual IC Time Burden (Hours)	3,720	-2,780	6,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.