Information Collection

2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)

IC 245877 under ICR 202107-0938-013 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10621 Partial Qualifying APM Participant (QP) Election (see SS-A Table 29) Form and Instruction
CMS-10621 Partial QP Election Form Appendix O Partial QP Submission Form.pdf Form and Instruction
CMS-10621 Partial QP Election Form Appendix O Partial QP Submission Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1430

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10621	Partial QP Election Form	Appendix O Partial QP Submission Form.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. 09â70â 0539	FR Citation: 83 FR 6587

Number of Respondents: 250	Number of Respondents for Small Entity: 250

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	250	-50	300
Annual IC Time Burden (Hours)	63	-12	75
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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