Document Name Document Type
Appendix A1 2022 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf Instruction
Appendix A1 2022 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf Instruction
Appendix B1 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet.pdf Instruction
Appendix B1 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet.pdf Instruction
CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Sub Appendix C1 2022 Qualified Clinical Data Registry (QCDR) measure submission template v4.0.pdf Form
CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Sub Appendix C1 2022 Qualified Clinical Data Registry (QCDR) measure submission template v4.0.pdf Form
Appendix A2 2022 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf CROSSWALK (Appendix A2): 2022 Qualified Registry Fact Sheet IC Document
Appendix A2 2022 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf CROSSWALK (Appendix A2): 2022 Qualified Registry Fact Sheet IC Document
Appendix B2 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet Crosswalk.pdf CROSSWALK (Appendix B2) 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet IC Document
Appendix B2 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet Crosswalk.pdf CROSSWALK (Appendix B2) 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet IC Document
Appendix C2 2022 Qualified Clinical QCDR Measure Submission Template vs Webform Crosswalk.pdf CROSSWALK (Appendix C2) 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template IC Document
Appendix C2 2022 Qualified Clinical QCDR Measure Submission Template vs Webform Crosswalk.pdf CROSSWALK (Appendix C2) 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2022 >> 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 2022 MIPS Qualified Registry Self-Nomination Fact Sheet.pdf	Yes	Yes	Printable Only
Instruction			Appendix B1 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet.pdf	Yes	Yes	Printable Only
Form	CMS-10621	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Appendix C1 2022 Qualified Clinical Data Registry (QCDR) measure submission template v4.0.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: 300	Number of Respondents for Small Entity: 300

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	300	35	265
Annual IC Time Burden (Hours)	2,402	437	1,965
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CROSSWALK (Appendix A2): 2022 Qualified Registry Fact Sheet	Appendix A2 2022 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf	09/01/2021
CROSSWALK (Appendix B2) 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet	Appendix B2 2022 MIPS Qualified Clinical Data Registry (QCDR) Self-Nomination Fact Sheet Crosswalk.pdf	09/01/2021
CROSSWALK (Appendix C2) 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Appendix C2 2022 Qualified Clinical QCDR Measure Submission Template vs Webform Crosswalk.pdf	09/01/2021

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

2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)

Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

OMB: 0938-1314

IC ID: 245873

View Information Collection (IC)