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

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⚠️ Notice: This information collection may be referencing outdated material.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
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 J Clinician Initiated Submission Form.docx Form
Appendix K Clinician Initiated Submission Form Crosswalk.docx Crosswalk IC Document

Information Collection (IC) Details

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 J Clinician Initiated Submission Form.docx		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: 150	Number of Respondents for Small Entity: 150

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Appendix K Clinician Initiated Submission Form Crosswalk.docx	11/22/2019

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