Information Collection

QECP Application, Reapplication, DUA and ARW

IC 198017 under ICR 202607-0938-003 · OMB 0938-1144.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10394 QECP Paper-Based Reapplication Form QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 Phase 1 Application Readiness Checklist QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 Phase 2 Application Readiness Checklist QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 Phase 3 Application Readiness Checklist QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 Qualified Entity Certification Program Data Security Review (QECP DSR) QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 Letter of Commitment Template QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 Extension Request Letter QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 Public Report Submission Form QECP Application, Reapplication, DUA and ARW	Form and Instruction
Form CMS-10394 QECP Data Source Attestation Workbook QECP Application, Reapplication, DUA and ARW	Form and Instruction
QECP-SUPP-DtaScrtyAdt.docx	Instruction
QECP-SUPP-MIWrqrmnts.docx	Instruction
QECP-SUPP-ARWRqmnts - Clean.docx	Instruction
CMS-10394 QECP Paper-Based Reapplication Form QECP-TEM-PprBsReappFrm_Clean.docx	Form and Instruction
CMS-10394 Phase 1 Application Readiness Checklist QECP-CHK-Phs1AppRdy - Clean.docx	Form and Instruction
CMS-10394 Phase 2 Application Readiness Checklist QECP-CHK-Phs2AppRdy.docx	Form and Instruction
CMS-10394 Phase 3 Application Readiness Checklist QECP-CHK-Phs3AppRdy.docx	Form and Instruction
CMS-10394 Qualified Entity Certification Program Data Security Rev QECP-DSR-clean.docx	Form and Instruction
CMS-10394 Letter of Commitment Template QQE-LOC-PRA- Clean.docx	Form and Instruction
CMS-10394 Extension Request Letter QECPProgramGuide.pdf	Form and Instruction
CMS-10394 Public Report Submission Form QECP-FORM-PblicRptExtnRqst - Clean.docx	Form and Instruction
CMS-10394 QECP Data Source Attestation Workbook QECP-WKB-SmpDtSceAttstn_Clean.xlsx	Form and Instruction
QECP-CHK-Phs1AppRdy_Redline.pdf Phase 1 App Readiness Checklist - Track change	IC Document
QECP-DSR_Redline.pdf QECP Data Security Review - Track Change	IC Document
QECP-FORM-PblicRptExtnRqst_Redline.pdf Public Report Submission Form - Track Change	IC Document
QECP-SUPP-ARWRqmnts_Redline.pdf Annual Report Worksheet Requirements - Track Change	IC Document
QECP-TEM-PprBsReappFrm_Redline.pdf QECP Paper-Based Reapplication Form - Track Change	IC Document
QQE-LOC-PRA- Redline.pdf Letter of Commitment - Track Change	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

QECP Application, Reapplication, DUA and ARW

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 401.703a 42 CFR 401.716 42 42 CFR 401.718 42 CFR 401.719(b) 42 CFR 401.713

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10394	Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10394	Yes	No	Fillable Printable
Form and Instruction	CMS-10394	Yes	No	Fillable Printable
Instruction		Yes	No	Printable Only
Form and Instruction	CMS-10394	Yes	No	Fillable Printable
Form and Instruction	CMS-10394	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10394	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10394	Yes	Yes	Fillable Printable
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Printable Only
Form and Instruction	CMS-10394	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10394	Yes	Yes	Fillable Printable

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: 40

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
	Requested	Previously Approved
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	5,800	5,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Phase 1 App Readiness Checklist - Track change		07/07/2026
QECP Data Security Review - Track Change		07/07/2026
Public Report Submission Form - Track Change		07/07/2026
Annual Report Worksheet Requirements - Track Change		07/07/2026
QECP Paper-Based Reapplication Form - Track Change		07/07/2026
Letter of Commitment - Track Change		07/07/2026

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

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