Application and Re-application processes

Application to Be a Qualified Entity to Receive Medicare Data for Performance Measurement (CMS-10394)

OMB: 0938-1144

IC ID: 198017

Information Collection (IC) Details

View Information Collection (IC)

Application and Re-application processes
 
No Modified
 
Voluntary
 
42 CFR 401.703a

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10394 Application QECP_PaperBased_ApplicationForm.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10294 QECP MEasure Production QA Worksheet QECP_MeasureProduction_QA_Worksheet.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10394 QECP Measure Information Workbook QECP_Measure_Information_Workbook.pdf Yes Yes Fillable Fileable Signable
Instruction QECP_Letter_of_Commitment.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10394 QECP Data Source Attestation QECP_DataSource_Attestation.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10392 QECP Data Security Workbook QECP_DataSecurity_Workbook.pdf Yes Yes Fillable Fileable Signable

Health Health Care Services

 

35 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 35 0 0 0 0 35
Annual IC Time Burden (Hours) 6,833 0 0 0 0 6,833
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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