Information Collection

(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)

IC 227506 under ICR 201907-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16) Form
CMS-10621 Hardship Exception Application Form Appendix R 2019 Hardship Exception Application Form.docx Form
CMS-10621 Extreme and Uncontrollable Circumstances Application For Appendix S 2019 Extreme and Uncontrollable Circumstances Application Form.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Hardship Exception Application Form	Appendix R 2019 Hardship Exception Application Form.docx		Yes	Yes	Fillable Fileable
Form	CMS-10621	Extreme and Uncontrollable Circumstances Application Form	Appendix S 2019 Extreme and Uncontrollable Circumstances Application Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,025	Number of Respondents for Small Entity: 6,025

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,025	-16	6,041
Annual IC Time Burden (Hours)	1,506	-4	1,510
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.