Information Collection

?414.1400 QCDR and qualified registry self nomination

IC 221782 under ICR 201611-0938-002 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10621 ?414.1400 QCDR and qualified registry self nomination Form and Instruction
CMS-10621 QCDR Self-nomination form MIPS PRA Appendix D-Qualified Registry and QCDR Self-nomination Form.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	§414.1400 QCDR and qualified registry self nomination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR §414.1400 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10621	QCDR Self-nomination form	MIPS PRA Appendix D-Qualified Registry and QCDR Self-nomination Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 183	Number of Respondents for Small Entity: 183

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	183	183
Annual IC Time Burden (Hours)	1,830	1,830
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.