KCCQ-10 Form

(CMS–10531) Transcatheter Mitral Valve Repair (TMVR) National Coverage Decision (NCD) (CMS-10531)

Documents and Forms

Document Name Document Type
Form CMS-10531 KCCQ-10 Form Form and Instruction
CMS-10531 KCCQ-10 Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (with PRA disclosure) 2021.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	KCCQ-10 Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10531	KCCQ-10	Kansas City Cardiomyopathy Questionnaire for Patients (with numbering) (with PRA disclosure) 2021.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,649	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25,947	14,256	11,691
Annual IC Time Burden (Hours)	3,027	1,663	1,364
Annual IC Cost Burden (Dollars)	0	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.