Initial Application

Application to Be a Qualified Entity to Receive Medicare Data for Performance Measurement

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.