Form CMS-10621 Partial QP Election Form

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2020 Qualifying APM Participant (QP) Performance Period
Partial QP Election Form
Dear [APM_Entity_Name]:
Based on CMS’ QP threshold calculations for performance year 2020 (payment adjustment year
2022), there are eligible clinicians in «APM_Entity_Name» that are Partial QPs. Accordingly,
[APM_Entity_Name] is to elect whether to report to MIPS. If [APM_Entity_Name] elects to report
to MIPS, all MIPS eligible clinicians in [APM_Entity_Name] that are Partial QPs will be subject to
the MIPS reporting requirements and payment adjustments for that year. To elect to report or
not report to MIPS, [APM_Entity_Name] is to complete and submit this election form accordingly
to [email protected] no later than March 31, 2021.
In the absence of making an explicit election, the MIPS eligible clinicians in [APM_Entity_Name]
will not participate in MIPS. Therefore, the Partial QPs in [APM_Entity_Name] will participate in
MIPS and receive a corresponding MIPS payment adjustment only if the APM Entity elects for
the eligible clinicians to participate in MIPS.
If [APM_Entity_Name] elects not to report to MIPS, the clinicians can still report to MIPS though
they will not be subject to the MIPS payment adjustment. This election is only applicable to
performance year 2020 (payment adjustment year 2022). If you have questions, please contact
[email protected].
Election Form
Please indicate whether [APM_Entity_Name] elects to report to MIPS by putting an “X” by one
of the options listed below:
☐ [APM_Entity_Name] elects to report to MIPS.
☐ [APM_Entity_Name] elects not to report to MIPS.
Signature
I certify that I am legally authorized to bind [APME] to this election.
Signature: ____________________________ Print Name: __________________________
Title: _________________________________ Date: __________________________
Please email the selected and signed form to
[email protected] by March 31, 2021.

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retained. If you have questions or concerns regarding where to submit your documents, please contact QPP at
[email protected]