Qis Implementation Plan And Progress Report Form Page 26
Download a blank fillable Qis Implementation Plan And Progress Report Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Qis Implementation Plan And Progress Report Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28QIS Implementation Plan and Progress Report Form
OMB 0938-1286
Expiration Date: 10/31/2018
Criterion 21b continued
In the space provided, please specify any additional health plans (outside of those already listed in
Criterion 21b) covered by the QIS by listing each plan’s unique 14-digit HIOS Plan ID (Standard
Component ID [SCID]). Indicate if each one is a new or existing health plan.
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
New Health Plan
Existing Health Plan
HIOS Plan ID (SCID)
pg. 26
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office
of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1286. The time required to
complete this information collection is estimated to average 48 hours. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Hud-40201 - Youthbuild Program Reports Part 5 Semi-annual Progress Report Form - U.s. Department Of Housing And Urban Development
Legal
Form Ie-sf Square Foot Rental (office, Retail, Warehouse And Restaurant) Income And Expense Reporting Form 2015
Financial
Form Dbpr Abt-6036 - Division Of Alcoholic Beverages And Tobacco Election Of Surcharge Calculation Method And Inventory Report Form
Business
Form De 88all-i - Change Of Address / Address Correction And Final Report Form - Employment Development Dept
Legal
Related Categories
Parent category: Medical