CMS-10818 Create A Ticket

Generic Clearance for the Center for Clinical Standards and Quality IT Product and Support Teams (CMS-10706)

CMS-10818 Create A Ticket - CCSQ Support Central Survey Mock-ups

OMB: 0938-1397

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Invitation

We've Received Your Ticket: CS########
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This should take about 2 minutes to complete.

What Happens Next...
PRA Disclosure Statement

Be on thetolookout
for anReduction
email conﬁrmation
from
zzz@z.com
(please
check to
your
spam
According
the Paperwork
Act of 1995, no
persons
are required
to respond
a collection
folder). Inquiries are processed in the order in which they are received, and an agent
of information unless it displays a valid OMB control number. The valid OMB control number for this
will reach back out to you promptly. Please use this ticket number in all further
information collection is 0938-XXXX
(Expires XX/XX/XXXX).
This inquiry.
is a voluntary information collection.
communications
regarding this
The time required to complete this information collection is estimated to average two minutes per
response,
including
the time toan
review
instructions,
search existing
data
resources,
thevia
data
If you have
not received
email
from zzz@zz.com,
please
Contact
Us gather
directly
needed, and complete and review the information
phone or collection.
email. 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

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****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Oﬃce. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not
be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact John Vancil – John.Vancil@cms.hhs.gov.

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EQRS
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Ticket Created Successfully
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We've Received Your Ticket: CS########

**Click here for demo purposes**
What Happens Next...
Be on the lookout for an email conﬁrmation from zzz@z.com (please check your spam
folder). Inquiries are processed in the order in which they are received, and an agent
will reach back out to you promptly. Please use this ticket number in all further
communications regarding this inquiry.
If you have not received an email from zzz@zz.com, please Contact Us directly via
phone or email.

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your feedback in a short survey.

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Programs

Accessiblity

QPP

Accessibility

Technical Support

iQIES/QIES
EQRS
HQR

IRequest
Have a Question
Support

About

Guided Tour

Ticket Created Successfully
THANK YOU

Export PDF

We've Received Your Ticket: CS########
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What Happens Next...
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Be on the lookout for an email conﬁrmation from zzz@z.com (please check your spam
We'd like are
for you
to stay. Your
feedback
is which
important
us. received, and an agent
folder). Inquiries
processed
in the
order in
theytoare
will reach back out to you promptly. Please use this ticket number in all further
communications regarding this inquiry.
Exit

Continue Survey

If you have not received an email from zzz@zz.com, please Contact Us directly via
phone or email.

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Provide Site Feedback

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your feedback in a short survey.

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About

Programs

Accessiblity

QPP

Accessibility

Technical Support

iQIES/QIES
EQRS
HQR

IRequest
Have a Question
Support

About

Guided Tour

Ticket Created Successfully
THANK YOU

Export PDF

We've Received Your Ticket: CS########

**Click
here for
demo purposes**
Thank you for
your
feedback!

What
Thank your for completing
out Happens
survey. Your Next...
opinions matter
to us and will help improve the overall experience.

Be on the lookout for an email conﬁrmation from zzz@z.com (please check your spam
folder). Inquiries are processed in the order in which they are received, and an agent
will reach back out to you promptly. Please use this ticket number in all further
communications regarding this inquiry.
If you have not received an email from zzz@zz.com, please Contact Us directly via
phone or email.

Return to homepage

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Provide Site Feedback

Help us improve this website by providing
your feedback in a short survey.

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Give Feedback

About

Programs

Accessiblity

QPP

Accessibility

Technical Support

iQIES/QIES
EQRS
HQR

We appreciate your feedback!
We appreciate your feedback!

*How easy was it to create a ticket?

Please rate your ability to create a ticket on our website:

Easy

Normal

Challenging

*How much do you agree with this statement?
The amount of time it took to create a ticket was reasonable.
Agree
Neither Agree or Disagree
Disagree

*Which program are you aﬃliated with?
Please select the program you are apart of:
EPCS - Electronic Prescribing for Controlled Substances
EQRS - End Stage Renal Disease Quality Reporting System
HQR - Hospital Quality Reporting
iQIES/QIES - Quality Improvement/Internet Quality Improvement &
Evaluation System
QPP - Quality Payment Program
CCSQ Services and Operations Support - QualityNet IT Services,
HARP, CCSQ Atlassian, ServiceNow & Slack
Other: (Please specify)

*How could we improve your next visit?
We value your insight!
I had a great experience!
I have a suggestion.

Please specify:

*Can we contact you with further questions?
May we contact you if we have additional questions?
Yes.

Please provide your contact details below:
Full Name:

Email Address:

No, thank you.

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File Type	application/pdf
File Modified	2022-07-22
File Created	0000-00-00