?414.1400 QCDR and qualified registry self nomination

Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

⚠️ Notice: This information collection may be referencing outdated material.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
Appendix A_QPP_Qualified_Registry_Self-Nomination_Fact_Sheet.pdf Qualified Registry Self Nomination Fact Sheet IC Document
Appendix B_QPP_QCDR_Self-Nomination_Fact_Sheet.pdf QCDR Self Nomination Fact Sheet IC Document

Information Collection (IC) Details

IC Title:	§414.1400 QCDR and qualified registry self nomination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR §414.1400 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 233	Number of Respondents for Small Entity: 233

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	233	50	183
Annual IC Time Burden (Hours)	2,330	500	1,830
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Qualified Registry Self Nomination Fact Sheet	Appendix A_QPP_Qualified_Registry_Self-Nomination_Fact_Sheet.pdf	07/13/2017
QCDR Self Nomination Fact Sheet	Appendix B_QPP_QCDR_Self-Nomination_Fact_Sheet.pdf	07/13/2017

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