CROSSWALK Appendix C : 2026 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative

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

All-Payer Clinician Initiated Submission Form
CY 2024 Final versus CY 2025 Final

Burden impact: The changes to this form reflect proposals in the CY 2025 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 39
Reason for Change:
Alignment with current year.
CY 2025 Final Rule text:
2025
CY 2026 Final Rule text:
2026
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Change #2:
Location: Page 1, Line 42
Reason for Change:
Alignment with current year.
CY 2025 Final Rule text:
December 1, 2025 for the 2025
CY 2026 Final Rule text:
December 1, 2025 for the 2025
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Change #3:
Location: Page 2, Line 9
Reason for Change:
Alignment with current year.
CY 2025 Final Rule text:
2024 for the 2025
CY 2026 Final Rule text:
2025 for the 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 by
Eligible Clinicians and APM Entities (or their authorized representatives) that participate in other payer arrangements to
request that CMS determine whether a payment arrangement is an Other Payer Advanced Alternative Payment Model
(APM) under the Quality Payment Program as set forth in 42 CFR § 414.1420. The time required to complete this
information collection is estimated to average 10 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 mandate 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.