Get Form Cms-10484 2015-2025

The Form CMS-10484 is essential for requesting application access within the ESRD Quality Incentive Program and related systems. Completing this form accurately is crucial to ensure timely processing and approval.

Follow the steps to fill out the Form CMS-10484 online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In Section 1, select the purpose of your request by checking only one box: Add new application role(s), Add additional application role(s), Change existing application role(s), or Remove application access.
3. Proceed to Section 2 to fill in your name and contact information. All fields marked with an asterisk (*) are required. For Middle Name, enter NMN if none.
4. Move to Section 3. Here, you will select the ESRD applications for which you are requesting access. Complete only one of the columns for each respective application (CROWNWeb, QIP, REMIS).
5. In Section 3.1 for CROWNWeb access, indicate whether you work for a Dialysis Facility, ESRD Network, CMS, or as Other Designated Users. Fill out the relevant details like CMS Certification Number, ESRD Network Number, and your role.
6. Continue with Section 3.2 for QIP access, completing one column based on your affiliation and role, similar to Section 3.1.
7. For REMIS access in Section 3.3, again choose your affiliation and complete the required role details.
8. In Section 4, the Applicant’s End User Manager (EUM) and Security Official (SO) must sign and date the form to authorize access. Ensure all required fields are complete before submission.
9. After assembling the form, save your changes and ensure legibility. You can download, print, or share the completed form as needed.

Ensure timely completion of your access request by following these steps online.