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

QualityNet Identity Management System (QIMS) Account Form

Documents and Forms

Document Name Document Type
Form CMS-10267 QualityNet Identity Management System (QIMS) Account Form (Subsequent Years) Form and Instruction
CMS-10267 QIMS- Account Registration Form CMS-10267.QIMS-CW_Account Registration_Form 8-8(final).docx Form and Instruction

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10267	QIMS- Account Registration Form	CMS-10267.QIMS-CW_Account Registration_Form 8-8(final).docx		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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	800	800
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.