Information Collection

MIPS: Virtual Group Election Process

IC 228101 under ICR 202005-0938-002 · OMB 0938-1343.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1343 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10652 MIPS: Virtual Group Election Process	Form and Instruction
CMS-10652 Virtual Group Agreement Template Appendix A Virtual Group Agreement Template.pdf	Form and Instruction

IC Title:

MIPS: Virtual Group Election Process

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10652	Virtual Group Agreement Template	Appendix A Virtual Group Agreement Template.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16

Number of Respondents for Small Entity: 16

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	16	16
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.