MIPS: Virtual Group Election Process

Virtual Groups for Merit-Based Incentive Payment System (MIPS) (CMS-10652)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.