Information Collection

Application and Re-application processes

IC 198017 under ICR 201806-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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
QECP Letter of Commitment Template.pdf	Instruction
QECP Letter of Commitment Template_Quasi QE.pdf	Instruction
CMS-10394 Application PaperBased_Application_Form_09292016.pdf	Form and Instruction
CMS-10394 QECP Measure Production QA Worksheet QECP_QA_Worksheet_8_16_2017.pdf	Form and Instruction
CMS-10394 QECP Measure Information Workbook QECP_Measure_Information_Workbook_8_16_20171.pdf	Form and Instruction
CMS-10394 QECP Data Source Attestation QECP_Data_Source_Attestation1.pdf	Form and Instruction
CMS-10394 QECP Data Security Workbook QECP Data Security Workbook-blank-11-131.pdf	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10394	Application	PaperBased_Application_Form_09292016.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10394	QECP Measure Production QA Worksheet	QECP_QA_Worksheet_8_16_2017.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10394	QECP Measure Information Workbook	QECP_Measure_Information_Workbook_8_16_20171.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			QECP Letter of Commitment Template.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10394	QECP Data Source Attestation	QECP_Data_Source_Attestation1.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10394	QECP Data Security Workbook	QECP Data Security Workbook-blank-11-131.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			QECP Letter of Commitment Template_Quasi QE.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10	-25	35
Annual IC Time Burden (Hours)	5,000	-1,833	6,833
Annual IC Cost Burden (Dollars)	0	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.