Information Collection

Application and Re-application processes

IC 198017 under ICR 201112-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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-10394 Application and Re-application processes	Form and Instruction
CMS-10394.QECP Operations Manual.pdf	Instruction
CMS-10394 Application for Qualified Entity Certification CMS-10394.QE Application (1-19-12).docx	Form and Instruction

IC Title:

Application and Re-application processes

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 401.703a

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-10394	Application for Qualified Entity Certification	CMS-10394.QE Application (1-19-12).docx		Yes	Yes	Fillable Fileable
Instruction			CMS-10394.QECP Operations Manual.pdf		Yes	Yes	Printable Only

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: 0

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
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	6,833	6,833
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.