Consolidated Renal Operations in a Web Enabled Network (CROWNWeb) Batch Data Submission Form

March 19, 2013

July 30, 2013

CROWNWeb Third-Party Batch Data Submission Authorization (Form CMS-10268)

Section # on Type of Change Rational for Change
Current CMS-10268

1. Dialysis Facility Added: Optional identification

Information CROWNWeb Facility ID information

(input not required)

Added: Optional identification

Batch Org Facility Code information

(input not required)

2. Corporate Entity or Added: CMS request

Vendor Information Corporate Entity or Vendor Number

(CMS use only)

Mailing Address to send Changed address to: New contract awarded
completed form to QualityNet Help Desk

1401 50^th Street, Suite 200

West Des Moines, IA 50266

Updated PRA Statement CMS Request

Form Title Changed form name in PRA pkg from Updated PRA package info to

“CROWNWeb Third-Party Submission match the actual name of the

Authorization” to “CROWNWeb Batch form in place since 5/27/2008

Data Submission Authorization”

(input not required)

Note: These changes are also documented in the Supporting Statement under:

• Section A. Background

• Section B. Justification, #11

• Both Section A. and B. contain the form name “CROWNWeb Batch Data Submission Authorization”