QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys

QIC Demonstration Evaluation Contractor (QDEC): Analyze Medicare Appeals to Conduct Formal Discussions and Reopenings with Suppliers

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1348 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10633 QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys Form and Instruction
CMS-10633 Web Based Surveys QDEC_Attachment A Web Based Survey_Revised for Passback.docx Form and Instruction

Information Collection (IC) Details

IC Title:	QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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-10633	Web Based Surveys	QDEC_Attachment A Web Based Survey_Revised for Passback.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,540	Number of Respondents for Small Entity: 1,524

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,540	2,540
Annual IC Time Burden (Hours)	423	423
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.