Information Collection

Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25)

IC 229075 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25) Form
CMS-10621 Eligible Clinician and APM Entity Requests for Other Pay Appendix D Clinician Initiated Submission Form (version 2).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1445

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)	Appendix D Clinician Initiated Submission Form (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: 150	Number of Respondents for Small Entity: 75

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	150	75	75
Annual IC Time Burden (Hours)	1,500	750	750
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.