Application and Re-application processes

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1144 can be found here:

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.