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⚠️ Notice: This information collection may be referencing outdated material.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 A1 2020 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf Instruction
Appendix B1 2020 MIPS QCDR Self-Nomination Fact Sheet.pdf Instruction
CMS-10621 2020 Qualified Clinical Data Registry (QCDR) Measure Sub Appendix C1 2021 QCDR Measure Submission Template.pdf Form
Appendix A2 2020 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf Crosswalk: 2020 Qualified Registry Fact Sheet IC Document
Appendix B2 2020 MIPS QCDR Self-Nomination Fact Sheet Crosswalk.pdf Crosswalk: 2020 Qualified Clinical Data Registry (QCDR) Fact Sheet IC Document
Appendix C2 2021 QCDR Measure Submission Template Crosswalk.pdf Crosswalk: 2020 Qualified Clinical Data Registry (QCDR) Measure Submission Template 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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Appendix A1 2020 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf	Yes	Yes	Fillable Fileable
Instruction			Appendix B1 2020 MIPS QCDR Self-Nomination Fact Sheet.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10621	2020 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Appendix C1 2021 QCDR Measure Submission Template.pdf	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	239	10	229
Annual IC Time Burden (Hours)	1,097	30	1,067
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk: 2020 Qualified Registry Fact Sheet	Appendix A2 2020 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf	08/20/2020
Crosswalk: 2020 Qualified Clinical Data Registry (QCDR) Fact Sheet	Appendix B2 2020 MIPS QCDR Self-Nomination Fact Sheet Crosswalk.pdf	08/20/2020
Crosswalk: 2020 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Appendix C2 2021 QCDR Measure Submission Template Crosswalk.pdf	08/20/2020

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