Appendix K 2024 Partial QP Election Form (for submission in CY 2025

OMB control number: 0938-134
Expiration Date: 02/28/2027

2024 Qualifying APM Participant (QP) Performance Period
Partial QP Election Form
Dear [APM_Entity_Name]:
Based on CMS’ QP threshold calculations for performance year 2024 (payment adjustment year
2026), there are eligible clinicians in «APM_Entity_Name» that are Partial QPs. Accordingly,
[APM_Entity_Name] is to elect whether to report to MIPS. If [APM_Entity_Name] elects to report
to MIPS, all MIPS eligible clinicians in [APM_Entity_Name] that are Partial QPs will be subject to
the MIPS reporting requirements and payment adjustments for that year. To elect to report or
not report to MIPS, [APM_Entity_Name] is to complete and submit this election form accordingly
to QualityPaymentProgramAPMHelpdesk@cms.hhs.gov no later than March 31, 2025.
In the absence of making an explicit election, the MIPS eligible clinicians in [APM_Entity_Name]
will not participate in MIPS. Therefore, the Partial QPs in [APM_Entity_Name] will participate in
MIPS and receive a corresponding MIPS payment adjustment only if the APM Entity elects for
the eligible clinicians to participate in MIPS.
If [APM_Entity_Name] elects not to report to MIPS, the clinicians can still report to MIPS though
they will not be subject to the MIPS payment adjustment. This election is only applicable to
performance year 2024 (payment adjustment year 2026). If you have questions, please contact
QualityPaymentProgramAPMHelpdesk@cms.hhs.gov.
Election Form
Please indicate whether [APM_Entity_Name] elects to report to MIPS by putting an “X” by one
of the options listed below:
☐ [APM_Entity_Name] elects to report to MIPS.
☐ [APM_Entity_Name] elects not to report to MIPS.
Signature
I certify that I am legally authorized to bind [APME] to this election.
Signature: ____________________________ Print Name: __________________________
Title: _________________________________ Date: __________________________
Please email the selected and signed form to
QualityPaymentProgramAPMHelpdesk@cms.hhs.gov by March 31, 2025.

OMB control number: 0938-134
Expiration Date: 02/28/2027

PRA Disclosure Statement
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 qpp@cms.hhs.gov.
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.