Information Collection

(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)

IC 229074 under ICR 201812-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction
CMS-10621 Promoting Interoperability Performance Category: Call fo Appendix H PI Measures Submission Form 2020 (version 2).docx	Form and Instruction
Appendix H Crosswalk.docx Appendix H Crosswalk	IC Document

IC Title:

(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1375

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10621	Promoting Interoperability Performance Category: Call for Measures Submission Form	Appendix H PI Measures Submission Form 2020 (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: 47

Number of Respondents for Small Entity: 47

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	47	7	40
Annual IC Time Burden (Hours)	24	4	20
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix H Crosswalk	Appendix H Crosswalk.docx	12/19/2018

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