Information Collection

CMS-367e – Quarterly VBP-MBP Data

IC 252230 under ICR 202203-0938-002 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-367e CMS-367e – Quarterly VBP-MBP Data Form
CMS Form-367e_Quarterly VBP-MBP_09.2021_Final.pdf Instruction
CMS Form-367e_Quarterly VBP-MBP_09.2021_Final.pdf Instruction
CMS-367e Quarterly VBP-MBP Data CMS Form-367e MDP Online Data Entry Mockup_09.2021.pdf Form
CMS-367e Quarterly VBP-MBP Data CMS Form-367e MDP Online Data Entry Mockup_09.2021.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CMS-367e â Quarterly VBP-MBP Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	CMS-367e	Quarterly VBP-MBP Data	CMS Form-367e MDP Online Data Entry Mockup_09.2021.pdf		Yes	Yes	Fillable Fileable
Instruction			CMS Form-367e_Quarterly VBP-MBP_09.2021_Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	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.