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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 229075 under ICR 201911-0938-009 · OMB 0938-1314.

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Document Type
Form
Form
IC Document
Information Collection (IC) Details

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Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25)
 
No Modified
 
Mandatory
 
42 CFR 414.1445

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

Health Health Care Services

Quality Payment Program (QPP), System No. 09–70– 0539  83 FR 6587

150 150
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150 0 0 0 0 150
Annual IC Time Burden (Hours) 1,500 0 0 0 0 1,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.