Information Collection

Quarterly VBP-MBP Data (CMS-367e)

IC 252230 under ICR 202606-0938-019 · OMB 0938-0578.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-367e Quarterly VBP-MBP Data Quarterly VBP-MBP Data (CMS-367e)	Form
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

IC Title:

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:

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				Yes	Yes	Fillable Fileable
Instruction					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
	Requested	Previously Approved
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].