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OMB Control No: 0938-1144	ICR Reference No: 202607-0938-003
Status: Received in OIRA	Previous ICR Reference No: 202404-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: OEDA
Title: Application To Be a Qualified Entity to Receive Medicare Data for Performance Measurement / Reapplication / Annual Report Worksheet (CMS-10394)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/17/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2027
Responses	70	70
Time Burden (Hours)	5,800	5,800
Cost Burden (Dollars)	0	0

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
QECP Application, Reapplication, DUA and ARW	CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394, CMS-10394	, , , , , , , ,

Annual Cost to Federal Government: $466,776

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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