Information Collection

Initial Application

IC 198017 under ICR 201106-0938-007 · OMB 0938-1144.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1144 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10392 Initial Application	Form and Instruction
CMS-10392 Qualified Entity Application CMS-10394.Draft_QE_Application.pdf	Form and Instruction
CMS-10394 Revised QE Application CMS-10394.REVISED QE Application(8-8-11).docx	Form and Instruction

IC Title:

Initial Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 401.7039(a)

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-10392	Qualified Entity Application	CMS-10394.Draft_QE_Application.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10394	Revised QE Application	CMS-10394.REVISED QE Application(8-8-11).docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

Number of Respondents for Small Entity: 35

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	17,500	17,500
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.