Form CMS-10267 CAS Account Form

Form Approved

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No. 0000-0000

CROWNWeb Authentication Service (CAS) Account Form 

Page 1 of this form must be NOTARIZED for New User Accounts using the same identification information that you, 
the Applicant, supplied to your local Security Administrator.  All Fields marked with an asterisk (*) are required.   
* Type of Request:          … Create New User Account                  … Change User Account                   … Disable User Account  
* Date Requested: (mm/dd/yyyy) 

* CAS/CROWNWeb User ID: (for Change/Disable) 

Personal Information 
Prefix: 
* First Name: 
Middle Name: 
* Last Name: 
Suffix: 

* Personal Address 1: 
* City: 
* State: 

Personal Address 2: 
* Zip Code 1: 
Zip Code 2: 

* Birthdate: (mm/dd/yyyy)  Home Phone: 
Cell Phone: 

(          ) 
(          ) 
Applicant must provide one of the following 4 types of Photo Identification: 
Identification Information  Driver's License, State Issued ID Card, Passport, Permanent Resident Card 
* Expiration Date: (mm/dd/yyyy)
* ID Number:  (specific to the ID) 
* Identification Used: 
* Issued By:  (state, country) 
(specify one of the 5 types) 

Business Information 
* Business Name: 

* Job Title: 
* Business Address 1: 

Business Address 2: 

* Your Manager’s Name: 

* Your Manager’s Job Title: 

* Email Address: 

* Phone Number: 
(          )                             Ext: 
* City: 

Fax Number: 
(          ) 
* State: 

* Zip Code 1: 
Zip Code 2: 

* Your Manager’s Email Address: 

* Your Manager’s Phone Number: 
(          ) 

Required Signatures 
My statements on this form are true, complete, and correct to the best of my knowledge and 
belief and are made in good faith.  I understand that a knowing and willful false statement on 
this form can be punished by fine or imprisonment or both. (See section 1001 of Title 18, 
United States Code).  I agree to the terms and conditions documented on Page 3 of this form. 
Authorization:  I acknowledge that our organization is responsible for all resources to be used 
by the Applicant/User identified above and that requested accesses are required to perform 
his or her duties. I have reviewed and verified the information supplied is accurate and 
appropriate. I understand that any change in employment status or access needs must be 
reported immediately to both (1) our designated Security Administrator and (2) the Helpdesk. 

* Signature of Applicant: 

* Signature of Manager: 

* Date: 
(mm/dd/yyyy) 
* Date: 
(mm/dd/yyyy) 

Notarization of Applicant’s Identity 
* Date: (mm/dd/yyyy) 

* Notary Expiration Date: (mm/dd/yyyy) 

* Notary Public Seal or Stamp: 

I attest that the Identification Information supplied by the Applicant on page 
1 of this form and presented to me confirms the identity of the Applicant. 
* Signature of Notary Public: 

FORM CMS-CAS-1000 (DRAFT 7) EF(05/01/2008) 

Page 1 of 3

Form Approved

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No. 0000-0000

CROWNWeb Authentication Service (CAS) Account Form 

Page 2 of this form does NOT require notarization.   All Fields marked with an asterisk (*) are required. 

CROWNWeb Roles and Scope 
* System Access Required for the Applicant’s Job Role: Complete ONE column only with the guidance of your Manager 
… Dialysis Facility 
CMS Medicare Provider Number 
(CMS Certification Number): 

Affiliated with ESRD Network #: 

Select at least one role: 
… Facility Viewer 
… Facility Editor 
… Facility Security Administrator 
Additional Scope Required Over 
the Following Facilities:  Provide the 

… ESRD Network 
ESRD Network #: 

Select at least one role: 
… Network Viewer 
… Network Patient Editor 
… Network Facility Editor 
… Network Security Administrator 

… System Administrator 
(SA) and Other Roles 
Office: 
Contract(s): 
Group: 

Division: 

CMS PO: 

Select at least one role: 
Select at least one role: 
… CMS Viewer 
… CAS SA 
… CMS Editor 
… CROWNWeb SA 
… CMS Security Administrator  … Helpdesk 
… Third Party Submitter 

… CMS Employee 

Medicare Provider Number for each; if 
more than 8, specify in blocks to the right. 

1.                                5. 
2.                                6. 
3.                                7. 
4.                                8. 

I have approved the CROWNWeb 
Roles and Scope for the Applicant: 

* Signature 
 of Manager: 

* Date: (mm/dd/yyyy) 

For Internal Use Only – Do Not Complete This Section if You are the Applicant or Manager 
This section to be completed by the Security Administrator and Helpdesk.  All Fields marked with an asterisk (*) are required. 
* Designated Security Administrator (SA):  * SA Phone Number: 
* SA Email Address: 

(          ) 
* Applicant CAS/CROWNWeb User ID:  * Account Creation Date: 
* Account Activation Date: 
… Training 
(mm/dd/yyyy) 
(mm/dd/yyyy) 
… Production 
Helpdesk Reason(s)  … Missing required * information                … Notarization                                            … Not an original form 
for Account  … Roles and/or scope                                      … Information Mismatch Between CAS Form and CAS Account 
Activation Denial:  … Other: (specify here) 
INSTRUCTIONS AND FORM ROUTING:
•

•

•

•
•

For Type of Request = Create New User Account: The Applicant and Manager must complete all required information on pages 1 and 2 of the form.
The Applicant must have page 1 of the original form notarized, and then provide original pages 1 and 2 to his or her designated Security
Administrator (SA). If you do not know who your SA may be, please check with your Manager; or call the QualityNet Help Desk on 1-866-288-8912.
If the SA is not co-located with the Applicant, the Applicant will mail pages 1 and 2 of the original form (and only their form) to the SA in a tamperproof package by United States Postal Service (USPS) Certified Mail with return receipt. It is a violation of Federal Systems Security to transmit this
form electronically using email, the Internet, or unsecured FAX. The Applicant may retain a copy of the original form for his or her personal records.
Upon receipt of pages 1 and 2 of the original form, the designated Security Administrator (SA) will create a new CAS/CROWNWeb account for the
Applicant. The SA will mail pages 1 and 2 of the original form to the Helpdesk. All forms will be mailed in tamper-proof packaging using United
States Postal Service (USPS) Certified Mail with return receipt. It is a violation of Federal Systems Security to transmit any form(s) electronically
using email, the Internet, or unsecured FAX. The SA shall NOT retain a copy of this form for any purpose.
Upon receipt of pages 1 and 2 of the original form, the Helpdesk will verify that the form (1) is original, (2) is complete, (3) contains either the raised
Notary seal or the Notary stamp with Notary license number, and (4) the required information entered into CAS by the designated SA matches the
required information on the original form. If all 4 of these criteria are met, the Helpdesk will activate the Applicant’s account, then store the original
form as required by law. The account cannot be activated if one or more of the 4 criteria are not met; in this case the Helpdesk will advise the user
and the SA of the action and the reason via a CAS system-generated email.
For Type of Request = Change User Account: Specify CAS/CROWNWeb User ID and Name, complete all areas on pages 1 and 2 which require
changes, obtain Applicant signature/date on page 1, and Manager signatures/dates on both pages 1 and 2. Notarization is not required except for a
change in the user’s name (any name field).
For Type of Request = Disable User Account: Specify CAS/CROWNWeb User ID and name, obtain Manager signature/date on page 1 (Manager
signature can be initially waived if the request involves a time-sensitive employee termination, but must subsequently be obtained within one
business day). Notarization is not required.

FORM CMS-CAS-1000 (DRAFT 7) EF(05/01/2008) 

Page 2 of 3

Form Approved

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No. 0000-0000

CROWNWeb Authentication Service (CAS) Account Form 

CROWNWEB DATA SUBMISSION STATEMENT 
Every CROWNWeb 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 pages 1 and 2 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. 

The information you furnish on page 1 of this form will be maintained by CMS in the CROWNWeb Authentication Service (CAS) application 
and the original form will be maintained by the QualityNet Helpdesk.  The data 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. 

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 CAS/CROWNWeb 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 CAS/CROWNWeb account
User ID and/or Password may have been compromised, you must immediately report that information to your
component’s designated Security Administrator (SA) and immediately contact the QualityNet Helpdesk at
1-866-288-8912 (qnetsupport@ifmc.sdps.org) to report the actual or potential security incident.
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 0000-0000. 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 the Notarization activity for new user accounts as required on page 1). 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.
FORM CMS-CAS-1000 (DRAFT 7) EF(05/01/2008) 

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