Information Collection

2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)

IC 227506 under ICR 202111-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16) Form
CMS-10621 Hardship Exception Application Form Appendix K1 2020 Promoting Interoperability Hardship Exception Application.pdf Form
CMS-10621 Hardship Exception Application Form Appendix K1 2020 Promoting Interoperability Hardship Exception Application.pdf Form
CMS-10621 Extreme and Uncontrollable Circumstances Application For Appendix L1 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf Form
CMS-10621 Extreme and Uncontrollable Circumstances Application For Appendix L1 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf Form
Appendix K2 2020 Hardship Exception Application Form Crosswalk.pdf Crosswalk - Hardship Exception Application Form IC Document
Appendix K2 2020 Hardship Exception Application Form Crosswalk.pdf Crosswalk - Hardship Exception Application Form IC Document
Appendix L2 2020 Extreme and Uncontrollable Circumstances Application Form CrossWalk.pdf Crosswalk - Extreme and Uncontrollable Circumstances Application Form IC Document
Appendix L2 2020 Extreme and Uncontrollable Circumstances Application Form CrossWalk.pdf Crosswalk - Extreme and Uncontrollable Circumstances Application Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1375

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Hardship Exception Application Form	Appendix K1 2020 Promoting Interoperability Hardship Exception Application.pdf		Yes	Yes	Fillable Fileable
Form	CMS-10621	Extreme and Uncontrollable Circumstances Application Form	Appendix L1 2020 Extreme and Uncontrollable Circumstances Reweighting Application.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: 52,099	Number of Respondents for Small Entity: 30,620

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-52,099	52,099
Annual IC Time Burden (Hours)	-13,025	13,025
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk - Hardship Exception Application Form	Appendix K2 2020 Hardship Exception Application Form Crosswalk.pdf	01/05/2021
Crosswalk - Extreme and Uncontrollable Circumstances Application Form	Appendix L2 2020 Extreme and Uncontrollable Circumstances Application Form CrossWalk.pdf	01/05/2021

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