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⚠️ Notice: This information collection may be referencing outdated material.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 2020 MIPS Registry Self-Nomination Fact Sheet.docx Instruction
Appendix C 2020 QCDR Self-Nomination Fact Sheet.docx Instruction
CMS-10621 2020 Qualified Clinical Data Registry (QCDR) Measure Sub Appendix E 2020 QCDR Measure Submission Template.xlsx Form
Appendix B Registry Self-Nomination Fact Sheet Crosswalk.docx Crosswalk: 2020 Qualified Registry Fact Sheet IC Document
Appendix D QCDR Self-Nomination Fact Sheet Crosswalk.docx Crosswalk: 2020 Qualified Clinical Data Registry (QCDR) Fact Sheet IC Document

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Appendix A 2020 MIPS Registry Self-Nomination Fact Sheet.docx	Yes	Yes	Fillable Fileable
Instruction			Appendix C 2020 QCDR Self-Nomination Fact Sheet.docx	Yes	Yes	Fillable Fileable
Form	CMS-10621	2020 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Appendix E 2020 QCDR Measure Submission Template.xlsx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Quality Payment Program (QPP), System No. 09–70– 0539	FR Citation: 83 FR 6587

Number of Respondents: 229	Number of Respondents for Small Entity: 229

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	229	-121	0	350
Annual IC Time Burden (Hours)	1,067	-1,479	-304	2,850
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk: 2020 Qualified Registry Fact Sheet	Appendix B Registry Self-Nomination Fact Sheet Crosswalk.docx	11/22/2019
Crosswalk: 2020 Qualified Clinical Data Registry (QCDR) Fact Sheet	Appendix D QCDR Self-Nomination Fact Sheet Crosswalk.docx	11/22/2019

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