CROSSWALK Appendix K: 2025 Partial QP Election Form (for submission in CY 2026)

OMB Control Number: 0938-1314
Expiration Date: 02/28/2027

Partial Qualifying APM Participant (QP) Election Form
CY 2025 Final versus CY 2026 Final
Burden impact: The changes to this form reflect policies in the CY 2026 Physician Fee
Schedule (PFS) Final Rule for the Quality Payment Program. There are no impacts to burden
as a result of these changes.
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Change #1:
Location: Page 1, Line 1
Reason for Change:
Updated performance year.
CY 2024 Final Rule text:
2025
CY 2025 Final Rule text:
2026
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Change #2:
Location: Page 1, Line 2
Reason for Change:
Updated payment adjustment year.
CY 2024 Final Rule text:
2025
CY 2025 Final Rule text:
2026
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Change #3:
Location: Page 1, Line 7
Reason for Change:
Updated calendar year for submission of form.
CY 2024 Final Rule text:
March 31, 2025
CY 2025 Final Rule text:
March 31, 2026
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Change #4:
Location: Page 1, Line 14
Reason for Change:
Updated performance year and payment adjustment year.
CY 2024 Final Rule text:
performance year 2024 (payment adjustment year 2026)
CY 2025 Final Rule text:
performance year 2025 (payment adjustment year 2027)

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Change #5:
Location: Page 1, End of document
Reason for Change:
Updated calendar year for submission of form.
CY 2024 Final Rule text:
Please email the selected and signed form to
[email protected] by March 31, 2025.
CY 2024 Final Rule text:
Please email the selected and signed form to
[email protected] by March 31, 2026.

According to the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), no persons are required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1314 (Expiration date: 2/28/2027). This information
collection is the tool to be used to request that CMS determine whether Eligible Clinicians are partial QPs
under the All-Payer Combination Option of the Quality Payment Program (QPP) as set forth in 42 CFR
414.1425. The time required to complete this information collection is estimated to average .25 hours per
response, including the time to review instructions, search existing data resources, gather the data
needed, to review and complete the information collection. This information collection is voluntary and all
information collected will be kept private in accordance with regulations at 45 CFR 155.260, Privacy and
Security of Personally Identifiable Information.  Pursuant to this regulation, CMS may only use or disclose
personally identifiable information to the extent that such information is necessary to carry out their
statutory and regulatory mandated functions. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850. If you have questions
or concerns regarding where to submit your documents, please contact QPP at [email protected].
Under the Privacy Act of 1974 (5 U.S.C. 552a) any personally identifying information obtained will be kept
private to the extent of the law.