Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)

Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

⚠️ Notice: This information collection may be referencing outdated material.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
Appendix A 2019-MIPS Qualified Registry Self-Nomination Fact Sheet (version 2).docx Instruction
Appendix B 2019-MIPS QCDR Self-Nomination Fact Sheet (version 2).docx Instruction

Information Collection (IC) Details

IC Title:	Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	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
Instruction			Appendix A 2019-MIPS Qualified Registry Self-Nomination Fact Sheet (version 2).docx		Yes	Yes	Fillable Fileable
Instruction			Appendix B 2019-MIPS QCDR Self-Nomination Fact Sheet (version 2).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	Number of Respondents for Small Entity: 350

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	350	117	233
Annual IC Time Burden (Hours)	2,850	520	2,330
Annual IC Cost Burden (Dollars)	0	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.