Qualified Registry or QCDR Vendors - Self Nomination

Physician Quality Reporting System (PQRS) (CMS-10276)

Documents and Forms

Document Name Document Type
Form CMS-10276 Qualified Registry or QCDR Vendors - Self Nomination Form
CMS-10276 Self Nomination Screen Shot - Self-nomination Form.docx Form

Information Collection (IC) Details

IC Title:	Qualified Registry or QCDR Vendors - Self Nomination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 414.90 42 CFR 414.92

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10276	Self Nomination	Screen Shot - Self-nomination Form.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Performance Measurement and Reporting System	FR Citation: 72 FR 52133

Number of Respondents: 150	Number of Respondents for Small Entity: 50

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	1,500	1,500
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.