Information Collection

QualityNet Identity Management System (QIMS) Account Form (Subsequent Years)

IC 186127 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10267 QualityNet Identity Management System (QIMS) Account Form (Subsequent Years)	Form and Instruction
CMS-10267 CMS-10267.QIMS- Account Registration Form CMS-10267.QIMS- Account Registration Form final4.doc	Form and Instruction

IC Title:

QualityNet Identity Management System (QIMS) Account Form (Subsequent Years)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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-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: 1,600

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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,600	-1,000	2,600
Annual IC Time Burden (Hours)	800	-500	1,300
Annual IC Cost Burden (Dollars)	0	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.