KCCQ-10 Form

(CMS–10531) Transcatheter Mitral Valve Repair (TMVR) National Coverage Decision (NCD)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1274 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10531 KCCQ-10 Form Form and Instruction
CMS-10531 KCCQ-10 508_short kccq 2012-01-31.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	KCCQ-10 Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10531	KCCQ-10	508_short kccq 2012-01-31.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	1,400	1,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.