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Federal forms, ICRs, and supporting documents

Information Collection

QECP Application, Reapplication, DUA and ARW

IC 198017 under ICR 202404-0938-006 · OMB 0938-1144.

Documents and Forms
Document Name
Document Type
Form and Instruction
Instruction
Instruction
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Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
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Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

QECP Application, Reapplication, DUA and ARW
 
No Modified
 
Voluntary
 
42 CFR 401.719(b) 42 CFR 401.703a 42 CFR 401.716 42 42 CFR 401.718 42 CFR 401.713

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10394 QECP Paper-Based Reapplication Form QECP-TEM-PprBsReappFrm.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10394 Phase 1 Application Readiness Checklist QECP-CHK-Phs1AppRdy.pdf Yes No Fillable Printable
Form and Instruction CMS-10394 Phase 2 Application Readiness Checklist QECP-CHK-Phs2AppRdy.pdf Yes No Fillable Printable
Instruction QECP-SUPP-DtaScrtyAdt.pdf Yes No Printable Only
Form and Instruction CMS-10394 Phase 3 Application Readiness Checklist QECP-CHK-Phs3AppRdy.pdf Yes No Fillable Printable
Form and Instruction CMS-10394 Qualified Entity Certification Program Data Security Review (QECP DSR) QECP-DSR.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10394 Letter of Commitment Template QECP-TEM-LtrCmmtmnt.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10394 Extension Request Letter QECPProgramGuide.pdf Yes Yes Fillable Printable
Instruction QECP-SUPP-MIWrqrmnts.pdf Yes No Printable Only
Instruction QECP-SUPP-ARWRqmnts.pdf Yes No Printable Only
Form and Instruction CMS-10394 Public Report Submission Form QECP-FORM-PbRptSubmsn.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10394 QECP Data Source Attestation Workbook QECP-WKB-SmpDtSceAttstn.xlsx Yes Yes Fillable Printable

Health Health Care Services

 

40 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 70 0 40 0 0 30
Annual IC Time Burden (Hours) 5,800 0 2,000 0 0 3,800
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.