Form CMS-10267 QIMS- Account Registration Form

Department of Health and Human Services

QualityNet Identity Management System (QIMS) Account Form

Account Information Part A Specify the type(s) of account that is being requested. If requesting a Security Official Account for an organization without one in place this form must be signed by a Notary of the Public who has satisfactorily proofed the identity of the individual.

* Type of Request:

 Create Regular User Account  Create End User Manager Account

 Create Security Official Account  Disable Account

Organization Level:

 CMS  Network  QIO  Facility  Third Party Submitter  Contractor

* Date Requested: (mm/dd/yyyy)

Personal Information ( Per NIST 800-63, Table 3, Level 3 the applicant must be seen in person and provide a government issued picture ID such as Drivers License with current address or Passport with nationality)

Prefix:

* First Name:

* Middle Name: (NMN if none)

* Last Name:

Suffix:

* Personal Address 1:

* City:

* State:

Personal Address 2:

* Zip Code:

Zip Code Extension:

* Birth date: (mm/dd/yyyy)

* Business Phone:

EXT:

* Cell Phone:

*Business E-mail Address (if none use personal e-mail address)

* Government Identification Used: (specify type)

* ID Number: (specific to the ID)

* Issued By: (state, country)

* Expiration Date: (mm/dd/yyyy), (for no expiration date enter 12/31/2100)

Business Information This information is provided to verify affiliation with a qualified healthcare organization.

* Business Name:

* Job Title:

* Business Address 1:

* City:

Fax Number:

Business Address 2:

* Zip Code 1:

Zip Code Extension:

* Your Manager’s Name:

* Your Manager’s Email Address:

* State:

* Your Manager’s Job Title:

* Your Manager’s Phone Number: Ext:

PART A (continued) *Notary instruction: Notary signature on this form is to confirm the identity of the Applicant only. The Notary is confirming that the applicant has a current government issued picture ID showing the same home address as is recorded on this registration form.

My statements on this form are true, complete, and correct to the best of my knowledge 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 5 of this form.

*Signature of Applicant

* Date: (mm/dd/yyyy)

Authorization: I acknowledge that our organization is responsible for all resources to be used by the Applicant/User identified on Page 1 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 Official and (2) the Help Desk.

* Signature of Manager: (End User Manager)

* Date: (mm/dd/yyyy)

Validation: I am attesting to the fact, that I have vetted the identification of the applicant requesting access to QIMS. The individual has provided the proper credentials as required per “NIST 800-63 Table 3, Level 3” and I have properly identified the credential used in the “Identification Used” section. By doing so, I am attesting to the fact that I properly vetted the identity of the applicant and he/she is in fact, the applicant requesting access. I understand that any change in name, employment status or access needs must be reported immediately to both (1) our designated Security Official and (2) the Help Desk.

* Signature of Identity Vetting Official: (Security Official)

* Date: (mm/dd/yyyy)

* Printed Name of Notary (* Required for Security Official accounts and when in-person proofing is not possible for all other accounts) I certify that the person identified on this document as the “Applicant” personally appeared before me this day and signed this document.

* Signature of Notary

*Date: (mm/dd/yyyy)

*Notary Seal/Stamp

Notary Stamp Expiration Date (mm/dd/yyyy)

*Application(s) to be accessed

 QIMS  QIO DDST  QIO MART  QualityNet.org  PQRS  CRMIS  Hospital Reporting  ESRD QIP  CROWNWeb

Part B of this form applies to CROWNWeb only. All Fields marked with an asterisk (*) are required.

CROWNWeb and ERSD QIP Roles and Scope Part B

Prefix:

* First Name:

* Middle Name: (NMN if none)

* Last Name:

Suffix:

* System Access Required for the Applicant’s Job Role: Complete ONLY ONE column with the guidance of your Manager

 Dialysis Facility

 ESRD Network

 CMS Employee

 Other Roles

CMS Medicare Provider Number (CMS Certification Number):

ESRD Network #:

Office: Group: Division:

Contract(s): CMS COTR:

ESRD Network #:

Select at least one role:  Facility Viewer  Facility Editor  Facility Administrator

 Network Viewer  Network Patient Editor  Network Facility Editor  Network Administrator

 CMS Viewer  CMS Editor  CMS Administrator

 Third Party Submitter for Batch  Third Party Researcher  CROWNWeb System Administrator  ESRD QIP System Administrator  ESRD QIP Special Purpose Contractor

Facility Scope “If the Applicant requires and is approved for Scope over more than ONE dialysis facility, the following section is required and must follow the SPECIAL ROUTING INSTRUCTIONS FOR ADDITIONAL FACILITY SCOPE on Page 4 of this form.

Facility Name:

Name of Facility Contact:

Contact Phone:

Contact E-mail:

Facility Name:

Name of Facility Contact:

Contact Phone:

Contact E-mail:

Facility Name:

Name of Facility Contact:

Contact Phone:

Contact E-mail:

Facility Name:

Name of Facility Contact:

Contact Phone:

Contact E-mail:

Facility Name:

Name of Facility Contact:

Contact Phone:

Contact E-mail:

I have authorized the CROWNWeb Roles and Scope, including any Additional Facility Scope for the Applicant

* Signature of Applicant’s End User Manager:

* Date: (mm/dd/yyyy)

Security Official Information: (This section is to be completed by the Security Official)

*QIMS Security Official (SO) Name:

* SO Phone Number:

* Date: (mm/dd/yyyy)

*Applicant QIMS User ID:

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

* Security Official Name (First, Middle Last)

*Security Official Signature:

Reason(s) for account Activation Denial (if applicable)

 Missing required * information  Notarization  Roles and/or scope

Instructions and Form Routing

INSTRUCTIONS AND FORM ROUTING for Part A:

For Type of Request = Create New User Account: The Applicant will fill in the on line registration form and submit it to the End User Manager (EUM) who will approve the new user for account creation. The Applicant will take part A of this form to the appointed Security Official (SO) where the Applicant will be required to perform Security Awareness Training and will undergo identity proofing. If the Applicant does not know who the assigned SO is, they can check with their EUM; or call the QualityNet Help Desk at 866-288-8912 or send an e-mail to qnetsupport@sdps.org.

• The Applicant must provide the registration form to the SO in person so the SO can act as the Identity Proofer. The Applicant may retain a copy of the original request form for his or her personal records.

• Choosing an endpoint for receipt of the 2^nd factor PIN is key to accessing any application that gathers Protected Healthcare Information (PHI) or Personally Identifiable Information (PII). Please select an option that is close to your computer workstation as you will want easy access to the PIN that is sent via your selected method of receipt.

• Upon receipt of part A of the original form, the designated SO will review the form to ensure it is complete, verify the EUM has signed the form and will then vet the user’s identity using a currently valid government picture identification document that lists the applicants current home address, or a passport showing the applicants nationality per NIST 800-63, Table 3, Level 3 E-Authentication recommendations. The SO will enter his/her name, and signature where designated on Part A of the form.

• Once identity vetting is complete, the SO will verify that the person requesting an account has completed the required Security Awareness Training (SAT). The SO will then log into QIMS and ensure the new user account is set up and assign the account holder to the proper QIMS role(s). Once the account has been set up the SO will mail the original form to the QualityNet Helpdesk for mandated record keeping. All forms will be mailed in tamper-resistant packaging using trackable mail with receipt by commercial carrier. It is a violation of Federal security regulations to transmit any form(s) electronically; email, the Internet, unsecure transmission media, or any unsecured FAX. The forms will be mailed to the QualityNet Help Desk Mailing Address:

Buccaneer, A Vangent Company

1401. 50th St. Suite 200

West Des Moines, IA 50266

Attn: QualityNet Help Desk

For Type of Account Request = Create Security Official Account: For first time SO accounts when there is not an existing SO to perform the above steps or there is not an SO within a reasonable distance the Applicant may fill out the registration form, Print it out and take it to a Notary of the Public for Identity proofing.

• At times there may be a Security Official at a facility near enough to conduct in person identity proofing for a nearby facility. Providing that there is an agreement in place to do this, it is authorized.

INSTRUCTIONS AND FORM ROUTING for Part B:

Upon receipt of the original Part B of this form:

• The EUM will review, approve and sign Part B of the form that is the application role request portion.

• Provisioning of application roles will be accomplished upon completion of any application related training by the SO or assigned local application system administrator following the QIMS User ID being activated.

• Note: the End User Manager will be pre-designated for the Facility, Help Desk, Network, QIO or CMS activity that the Applicant is closest to.

• The Security Official will verify that the each form; (1) is the original, (2) is complete, (3) has the required SO information completed. (4) Is signed by the EUM. If all of these criteria are met, the Security Official will store the original Part B form locally for a period no less than 7.5 years and update the form whenever there is a change in access required by the User.

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 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 QualityNet Identity Management System (QIMS) and the original form will be maintained by the Identity Management Team. 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 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 your component’s designated Security Official (SO) and immediately contact the QualityNet Helpdesk 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 0938-1050. 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 Security Officer 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-QIMS-0001 (05/11v)

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