Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary Removed 0 0 0 Other-Appendix A1 (See Table 3): 2022 Qualified Registry Fact Sheet (Revised)
Other-Appendix B1 (See Table 4): 2022 Qualified Clinical Data Registry (QCDR) Fact Sheet (Revised)
Form and Instruction CMS-10621 Appendix D1 (See Table 27): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised)
Form and Instruction CMS-10621 Appendix E1 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submissi
Form and Instruction CMS-10621 Appendix F1 (See Table 29): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised)
Form and Instruction CMS-10621 Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised)
Form and Instruction CMS-10621 Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised)
Form and Instruction CMS-10621 Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised)
Form and Instruction CMS-10621 Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised)
Form and Instruction CMS-10621 Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised)
Form and Instruction CMS-10621 Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New)
Form and Instruction cms-10621 Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform)
Form and Instruction cms-10621 Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change)
Form and Instruction cms-10621 Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change)
Form and Instruction CMS-10621 Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)
CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary Modified 344023 1469234 0 Form and Instruction Appendix A 2023 QCDR and Registry Self-nomination User Guide
Form Appendix B Payer Initiated Submission Form
Form Appendix C Eligible Clinician Initiated Submission Form
Form Appendix D Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
Form Appendix E Data Template for Candidate Measures
Form Appendix F 2022 Peer Reviewed Journal Article Requirement Template
Form Appendix G Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form
Form Appendix H Improvement Activities Performance Category, 2022 Call for Activities Submission Form
Form Appendix I 2021 Hardship Exception Application Form
Form Appendix J 2021 Extreme and Uncontrollable Circumstances Application Form
Form and Instruction Appendix K 2022 MVP Candidates: Instructions and Template
Form Appendix L 2020 Partial QP Election Form
Total burden requested under this ICR: 344023 1469234 0  
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