Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
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 401.719(b)
42 CFR 401.716 42
42 CFR 401.718
42 CFR 401.713
Information Collection Instruments:
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
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 %
Requested
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
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.