Information Collection

Application and Re-application processes

IC 198017 under ICR 202203-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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
6_Reapplicaiton Requiremetns List .pdf	Instruction
6_Reapplicaiton Requiremetns List .pdf	Instruction
QECPProgramGuide.pdf	Instruction
QECPProgramGuide.pdf	Instruction
CMS-10394 Application 6_PaperQECPReapplication.pdf	Form and Instruction
CMS-10394 Application 6_PaperQECPReapplication.pdf	Form and Instruction
CMS-10394 QECP Measure Production QA Worksheet 4_QE CP Phase 3 App List_Final.pdf	Form and Instruction
CMS-10394 QECP Measure Production QA Worksheet 4_QE CP Phase 3 App List_Final.pdf	Form and Instruction
CMS-10394 QECP Measure Information Workbook 5_QECP Phase 3 MIW List_Final.pdf	Form and Instruction
CMS-10394 QECP Measure Information Workbook 5_QECP Phase 3 MIW List_Final.pdf	Form and Instruction
CMS-10394 QECP Phase 1 Data Source Attestation Requirements 2_QECP Phase 1 DSA Requirements_Final.pdf	Form and Instruction
CMS-10394 QECP Phase 1 Data Source Attestation Requirements 2_QECP Phase 1 DSA Requirements_Final.pdf	Form and Instruction
CMS-10394 Qualified Entity Certification Program Data Security Rev 3_QECP Data Security Review 2020 FINAL v1.1_508.pdf	Form and Instruction
CMS-10394 Qualified Entity Certification Program Data Security Rev 3_QECP Data Security Review 2020 FINAL v1.1_508.pdf	Form and Instruction
CMS-10394 Letter of Commitment Template 5 QECP Letter of Commitment Template.pdf	Form and Instruction
CMS-10394 Letter of Commitment Template 5 QECP Letter of Commitment Template.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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	6_PaperQECPReapplication.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10394	QECP Measure Production QA Worksheet	4_QE CP Phase 3 App List_Final.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10394	QECP Measure Information Workbook	5_QECP Phase 3 MIW List_Final.pdf	Yes	Yes	Fillable Printable
Instruction			6_Reapplicaiton Requiremetns List .pdf	Yes	Yes	Printable Only
Form and Instruction	CMS-10394	QECP Phase 1 Data Source Attestation Requirements	2_QECP Phase 1 DSA Requirements_Final.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10394	Qualified Entity Certification Program Data Security Review (QECP DSR)	3_QECP Data Security Review 2020 FINAL v1.1_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10394	Letter of Commitment Template	5 QECP Letter of Commitment Template.pdf	Yes	Yes	Fillable Printable
Instruction			QECPProgramGuide.pdf	Yes	Yes	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	30	20	10
Annual IC Time Burden (Hours)	3,800	-1,200	5,000
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.