Qies Access Request PDF Details

The QIES (Quality Improvement and Evaluation System) National Data Access Request form is an essential document for individuals seeking access to a vast array of reports and data related to healthcare quality improvement. This form is meticulously designed to cater to a diverse group of users including CMS (Centers for Medicare & Medicaid Services) staff, state survey agencies, contractors, and other specified user types, by allowing them to request new user IDs, change access levels, or delete user IDs effectively. It comprehensively covers various sections such as the type of request, specific access requested including to CASPER reports, MDS (Minimum Data Set) reports, OASIS (Outcome and Assessment Information Set) reports, and more detailed options under QIES Workbench and ASPEN Web Access among others. Moreover, this form enlists supervisor authorization and CMS authorizations crucial for processing the request, ensuring that all accesses are properly supervised and authorized to uphold data integrity and security. The importance of adhering to the privacy act and security requirements is strongly emphasized, reflecting the form's role in facilitating secure and authorized access to sensitive healthcare data. This document, revised on March 31, 2015, serves as a bridge between the need for critical healthcare data and ensuring that such data is handled responsibly and ethically, under the guidelines of the Privacy Act of 1974 and the Computer Security Act of 1987, to protect individual privacy and the security of federal information systems.

QuestionAnswer
Form NameQies Access Request
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescms qies corporate access request form, qies access request form, tinyurl choice passwords, access do qies

Form Preview Example

QIES National Data Access Request.

Please complete this form electronically, print, and sign hard copy to submit

Type of Request

New User ID

Change Access

Delete User ID

Existing QIES User ID (CASPER, QW, ASPEN Web):

Access Requested For

Type of User:

CMS

State Survey Agency

Contractor

DUA Number:

 

 

 

DUA Expiration Date:

 

 

 

 

 

Requester Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last, First, Middle Initial

 

Other:

Carrier Number (MAC Only):

Title:

Organization:

User Location: City: Work Phone Number: Work E-mail Address: Access to States:

State: Extension:

Request Date:

CASPER Reports Access

MDS NH Reports

MDS SB Reports

OASIS Reports (inc. OBQI/OBQM Mgmt)

Survey & Certification Reports

 

CLIA MSA Report 91

IRF-PAI Management

IRF-PAI Administration

MDS QI

MDS NH Assessment

QIES Workbench Access

OBQI

Survey and Certification (Includes Provider/Enforcement (AEM) and CLIA data)

 

The QIES Workbench data groups below contain patient-level (privacy) data

 

 

MDS SB

OASIS

IRF-PAI

LTCH

Hospice

ACTS

Assessment

Assessment

Assessment

Assessment

Assessment

 

ASPEN Web Access

CLIA

ASSURE

Other Access

RHHI Extract

MDS NH Extract

MDS 3.0 NH Viewer

MDS Training Worksheet

IRF-PAI Viewer

MDS 3.0 DMS

MDS SB Extract

Swing Bed Viewer

OASIS Training Worksheet

QTSO

OASIS DMS

OASIS Viewer

 

 

 

Other access not listed:

 

 

 

 

 

 

 

 

Business need for the

 

 

 

 

 

 

 

 

 

 

 

 

requested access:

 

 

 

 

 

 

 

 

 

 

Supervisor Authorization -

Supervisor Authorizer Name:

 

 

 

 

 

 

 

 

Last, First, Middle Initial

 

 

 

 

Supervisor Authorizer Phone:

 

Ext:

 

 

 

 

 

Required for Approval

Supervisor Authorizer Signature: (sign in black or blue ink)

Date:

CMS Regional Office CMS Authorizer Name:

CMS Authorizer Phone:

CMS Authorization - Required for Approval

CMS Central Office

CMS Authorizer Signature: (sign in black or blue ink)

Last, First, Middle Initial

Ext:

 

Date:

 

 

 

QIES National Data Access Request - Revised 03/31/2015

PRIVACY ACT ADVISORY STATEMENT

Privacy Act of 1974, P.L. 93-579

The information on side 1 of this form is collected and maintained under the authority of Title 5 U.S. Code, Section 552a(e)(10). 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 stature, except in limited circumstances.

The information you furnish on this form will be maintained in the Individuals Authorized Access to the Centers for Medicare & Medicaid Services (CMS) Data Center System of Records and may be disclosed as a routine use disclosure under the routine uses established for this system as published at 59 FED. REG. 41329 (08-11-94) and as CMS may establish in the future by publication in the Federal Register.

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 systems, the Computer Security Act of 1987 requires 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 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 IDENTIFICATION NUMBER AND/OR PASSWORD to someone else. They are for your use only and will serve as your “electronic signature”. This means that you may be held responsible for the consequences of unauthorized or illegal transactions.

-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 sub 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 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 systems access privileges and/or disciplinary/ adverse action up to and including removal from Federal Service, depending upon the seriousness of the offense. 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 illegally.

If you become aware of any violation of these security requirements or suspect that someone else may have used your identification number or password, immediately report that information to your security officer.

Signature of User: (sign in black or blue ink)

Date:

Printed User's Name:

How to Edit Qies Access Request Online for Free

The whole process of filling in the tinyurl choice passwords is actually comparatively quick. Our experts made sure our software is easy to use and can help fill in any kind of PDF in no time. Explore some of the simple steps you will need to follow:

Step 1: The page includes an orange button stating "Get Form Now". Click it.

Step 2: So you should be on your file edit page. You can add, transform, highlight, check, cross, add or delete fields or words.

For each segment, fill out the data asked by the software.

step 1 to writing cms qies corporate access request form

Please type in the information within the segment MDS NH Assessment, MDS SB Assessment, OASIS Assessment, IRFPAI Assessment, LTCH Assessment, Hospice Assessment, ACTS, ASPEN Web Access CLIA, ASSURE, Other Access, RHHI Extract, MDS NH Extract, MDS NH Viewer, MDS Training Worksheet, and IRFPAI Viewer.

cms qies corporate access request form MDS NH Assessment, MDS SB Assessment, OASIS Assessment, IRFPAI Assessment, LTCH Assessment, Hospice Assessment, ACTS, ASPEN Web Access CLIA, ASSURE, Other Access, RHHI Extract, MDS NH Extract, MDS NH Viewer, MDS Training Worksheet, and IRFPAI Viewer blanks to fill out

You may be instructed to provide the particulars to help the application complete the area Supervisor Authorizer Phone, Ext, Date, CMS Authorization Required for, CMS Regional Office, CMS Central Office, CMS Authorizer Name, Last First Middle Initial, CMS Authorizer Signature sign in, CMS Authorizer Phone, Ext, Date, and QIES National Data Access Request.

stage 3 to completing cms qies corporate access request form

The Signature of User sign in black or, Date, and Printed Users Name area will be used to record the rights or responsibilities of both sides.

Entering details in cms qies corporate access request form step 4

Step 3: Press the "Done" button. Now it's possible to upload your PDF form to your electronic device. As well as that, you may send it by email.

Step 4: You will need to get as many duplicates of your file as you can to keep away from future problems.

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