CMS-10268 Crownweb Batch Data Submission Authorization form

Form Approved
OMB No. 0938-1052

CROWNWeb Batch Data Submission Authorization Form
Page 1 of this form must be completed to establish a delegation of authority for a Corporate Entity or Vendor to submit data on
behalf of a Dialysis Facility to CMS. All Fields marked with an asterisk (*) are required.
* Type of Request:
 Create Delegation of Authority
 Revoke Delegation of Authority
*Date of Request: (mm/dd/yyyy)

(A) Dialysis Facility Information
*Facility Name:

CROWNWeb Facility ID:

Batch Org Facility Code:

*Corporate/Vendor Affiliation:
*Business Address 1:

*Phone Number:
(
)
*City:

Fax Number:
(
)
*State:

Business Address 2:

* Zip Code 1:

Zip Code 2:

Facility Contact Name:

*Facility Administrator Name:

Facility Contact Phone:
(
)
Facility Contact Email Address:

*Facility Administrator Phone:
(
)
*Facility Administrator Email Address:

(B) Corporate Entity or Vendor Information
*Organization Name:
*Business Address 1:

*City:

*State:

Business Address 2:

*Zip Code 1:

Zip Code 2:

*Organization Contact Name:

*Phone Number:
Fax Number:
(
)
(
)
Corporate Entity or Vendor Number: (CMS Use Only)

*Organization Contact Email Address:

(C) Authorization for Facility‐Collected Data Submission into CROWNWeb
The Dialysis Facility specified in (A) authorizes the Corporate Entity/Vendor specified in (B) to transmit data, view data, and/or update
data according to the following chart:
(1) Transmit CROWNWeb data and receive
 Patient data
* Allow  Do Not Allow *Effective Date:
validation errors and information
 Facility data
* Allow  Do Not Allow (mm/dd/yyyy)
(2) Allow viewing of CROWNWeb data
 Patient data
* Allow  Do Not Allow *Effective Date:
 Facility data
* Allow  Do Not Allow (mm/dd/yyyy)
(3) Allow updating of CROWNWeb data
 Patient data
* Allow  Do Not Allow *Effective Date:
 Facility data
* Allow  Do Not Allow (mm/dd/yyyy)
The corporate entity/vendor (1) agrees to transmit data for all payers via CROWNWeb in the agreed‐upon data format provided by CMS
(XML format), and (2) certifies that all of its data collection and transmission activities are in accordance with all HIPAA regulatory
requirements regarding security and privacy. This authorization shall remain in effect until the Facility Administrator informs CMS of changes
through the ESRD Network Organization with facility jurisdiction or through the QualityNet Help Desk (see below).
* CMS Medicare Provider Number:
National Provider Identifier (NPI):
*Facility Administrator Signature: (Must be original signature)

*Date Signed: (mm/dd/yyyy)

Mail completed form to: QualityNet Help Desk, 1401 50th Street, Suite 200, West Des Moines, IA 50266

FORM CMS-10268 EF(04/25/2013)

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Form Approved
OMB No. 0938-1052

PRIVACY ACT STATEMENT
The information on page 1 of this form is collected and maintained under the authority of Title 5 U.S. Code, Section 552a(e)(10) (The
Privacy Act of 1974). This information is used for assigning, controlling, tracking, and reporting authorized access to and use of CMS’s
computerized information and resources. The Privacy Act prohibits disclosure of information from records protected by the statute,
except in limited circumstances.
The information you furnish on page 1 of this form will be maintained by CMS in the CROWNWeb Authentication Service (CAS)
application and the original form will be maintained by the QualityNet Help Desk,1-866-288-8912 ([email protected]).
The data may be disclosed as a routine use disclosure under the routine uses established for this system as published at 59
FED.REG.41329 (08‐11‐94) and as CMS may establish in the future by publication in the Federal Register.
Furnishing the information on this form is voluntary. However, if you do not provide this information, you may not be granted access
to CMS computer systems.

PAPERWORK REDUCTION ACT STATEMENT
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information is 0938-1052. The time required to
complete this information collection is estimated to average 5 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
The Centers for Medicare and Medicaid Services
Attention: PRA Reports Clearance Officer
Mailstop C4‐26‐05
7500 Security Boulevard Baltimore, Maryland 21244‐1850.

FORM CMS-10268 EF(04/25/2013)

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