E-Application Screenshots_2022

CCQAS Agency Disclosure Notice Placeholder and Screenshots
All CCQAS users are presented with the below statement and warning banner upon login to the web based
application. This statement and banner will be updated to include the Agency Disclosure Notice with the language
displayed below in the red text box. Updates to this page require code change, which is costly and timely, and
must be scheduled as part of the CCQAS sustainment vendor’s future work. This change will be made when the
OMB Control Number and Expiration Date has been finalized.

AGENCY DISCLOSURE NOTICE
OMB CONTROL NUMBER: [XXXX-XXXX]
OMB EXPIRATION DATE: [MM/DD/YYYY]
The public reporting burden for this collection of information, [Insert OMB Control
Number], is estimated to average four hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding the burden
estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at [email protected].
Respondents should be aware that notwithstanding any other provision of law, no person
shall be subject to any penalty for failing to comply with a collection of information if it does
not display a currently valid OMB control number.

The following screenshots depict the data fields within CCQAS where information is collected for a health care
provider.
Once a Military Health System (MHS) health care provider has gained access to CCQAS, a new Credentials record
is generated. A single Credentials record is maintained in CCQAS for each health care provider over the entirety of
his or her service to the MHS and is updated overtime to reflect the provider’s qualifications to provide clinical
care. This information collection occurs by manual entry into CCQAS. Health care providers supply demographic
information, licensure, certification, education and training, work history, professional specialties, and health
status in a Credentials record.
Additionally, documents are uploaded and attached to a provider’s Credentials record to be validated by a
Credentials manager. For certain provider types that require privileges to deliver care, completion of an electronic
application (E-application) occurs (reference pages 41-44 here within). The Credentials record and electronic
application provide the basis for the MHS’ credentialing and privileging processes.