Form Cms 10484 – Fill Out and Use This PDF

ESRD Application Access Form

QUALITYNET DATA SUBMISSION STATEMENT

Every QualityNet system user agrees, based on his or her best knowledge, information, and belief, that the data they submit to CMS is accurate, complete, and truthful.

PRIVACY ACT STATEMENT

The information on page 1 of this form is collected and maintained under the authority of Title 5 U.S. Code, Section 552a(e)(10) (The Privacy Act of 1974). This information is used for assigning, controlling, tracking, and reporting authorized access to and use of CMS’s computerized information and resources. The Privacy Act prohibits disclosure of information from records protected by the statute, except in limited circumstances. This form is maintained locally by your component Security Official (SO). If an Administrator role is selected and approved, this form is maintained by the QualityNet Help Desk ESRD Team.

Furnishing the information on this form is voluntary. However, if you do not provide this information, you may not be granted access to CMS computer systems.

SECURITY REQUIREMENTS FOR USERS OF CMS COMPUTER SYSTEMS

CMS uses computer systems that contain sensitive information to carry out its mission. Sensitive information is any information which the loss, misuse, or unauthorized access to, or modification of could adversely affect the national interest, or the conduct of Federal programs, or the privacy to which individuals are entitled under the Privacy Act. To ensure the security and privacy of sensitive information in Federal computer systems, the Computer Security Act of 1987 requires Federal agencies to identify sensitive computer systems, conduct computer security training, and develop computer security plans. CMS maintains a system of records for use in assigning, controlling, tracking, and reporting authorized access to and use of CMS’s computerized information and resources. CMS records all access to its computer systems and conducts routine reviews for unauthorized access to and/or illegal activity.

Anyone with access to CMS Computer Systems containing sensitive information must abide by the following:

●Do not disclose or lend your QIMS ACCOUNT USER ID and/or PASSWORD to someone else. They are for your use only and serve as your “electronic signature”. This means that you may be held responsible for the consequences of unauthorized or illegal transactions executed under your account.

●Do not browse or use CMS data files for unauthorized or illegal purposes.

●Do not use CMS data files for private gain or to misrepresent yourself or CMS.

●Do not make any disclosure of CMS data that is not specifically authorized.

●Do not duplicate CMS data files, create extract files of such records, remove or transmit data unless you have been specifically authorized to do so.

●Do not change, delete, or otherwise alter CMS data files unless you have been specifically authorized to do so.

●Do not make copies of data files, with personal identifiable data, or data that would allow individual identities to be deduced unless you have been specifically authorized to do so.

●Do not intentionally cause corruption or disruption of CMS data files.

A violation of these security requirements could result in termination of CMS systems access privileges. In addition, Federal, State, and/or local laws may provide criminal penalties for any person illegally accessing or using a Government‐owned or operated computer system for illegal activities.

If you become aware of any violation of the above security requirements or suspect that your QIMS account User ID and/or Password may have been compromised, you must immediately report that information to the designated Security Official (SO) assigned to your component and immediately contact the QualityNet Help Desk at 1-866-288-8912 (qnetsupport@sdps.org) to report the actual or potential security incident.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is FORM CMS-ESRD-0223. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, complete the form, and review the information collection (this does not include obtaining signatures as required on page 1 Section 4). If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: The Centers for Medicare and Medicaid Services, Attention: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

ESRD Application Access Form

INSTRUCTIONS AND FORM ROUTING

The following instructions are intended to assist Applicants with completing this form to add or change roles in CROWNWeb and/or ESRD Quality Improvement Program (QIP) applications or to remove access to one or both applications.

This form was previously known as and replaces Part B of the QualityNet Identity Management System (QIMS) Account Form.

An Applicant must first have an active QIMS user account in order to request access to ESRD applications via this form.

If you need a QIMS user account, you must first complete Part A of the QualityNet Identity Management System (QIMS) Account Form and be approved and provisioned by your End User Manager (EUM) and Security Official (SO).

Please print clearly or type when completing this form. It will be returned to you if your form is not complete and legible; this may delay your request for application access.

All fields marked with an asterisk (*) are required and must be filled out by the Applicant.

SECTION 1

Please check only one Purpose of Request:

Add new application role(s): check if you are requesting application access to CROWNWeb and/or QIP for the first time

Add additional application role(s): check if you have access to one application but need to add either CROWNWeb or QIP

Change existing application role(s): check if you are changing your role and/or scope in existing applications you access

Remove application access: check if you are requesting removal of application access to CROWNWeb and/or QIP

SECTION 2

Please complete all required fields; these fields are marked with an asterisk (*). If you have no Middle Name enter NMN in that field.

Prefix (Mr., Mrs., Ms., Dr., etc.); Suffix (Jr., Sr., II, III, M.D., Ph.D., Esq., etc.)

You should already have a Current QIMS User ID, but if your QIMS Account Form is in process leave this field blank.

SECTION 3

Select the ESRD application(s) for which you are requesting a new role, changing a role, or from which you are removing user access. You can use this form for CROWNWeb or QIP or both systems.

Section 3.1 ESRD CROWNWeb Access Request: check box to request a new role, change a role or remove user access to the CROWNWeb application

Complete only one of the following columns:

ODialysis Facility: select if you are an employee of a dialysis facility and complete the following:

CMS Medicare Provider Number (CMS Certification Number)

ESRD Network # (1‐18)

Select the facility role(s) you will be performing in CROWNWeb:

Facility Viewer

Facility Editor

Facility Administrator

Additional Facility Scope for Applicants requiring CROWNWeb scope over more than one Dialysis Facility: complete if applicable by listing up to 5 Facilities; attach a separate sheet to list more than 5 Facilities

OESRD Network: select if you are an employee of an ESRD Network and complete the following:

ESRD Network # (1‐18)

Select the Network role(s) you will be performing in CROWNWeb:

Network Viewer

Network Patient Editor

Network Facility Editor

Network Administrator

OCMS Employee: select if you are an employee of CMS and enter the following:

Office, Group, Division

Select the role(s) you will be performing in CROWNWeb:

CMS Viewer

CMS Editor

CMS Administrator

OOther Designated Users: select if you are a CMS designee to use CROWNWeb and enter the following:

Contract Number(s) and CMS Contracting Officer Representative (COR) if applicable