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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.