View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Inpatient Psychiatric Facility Quality Reporting Program
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10432 Reconsideration Request Form CMS IPF Recon Request Paper Form_final_508.pdf No No Fillable Fileable
Form and Instruction CMS-10432 Data Accuracy and Completeness CMS IPF DACA Paper Form_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Data Accuracy and Completeness Screen Shots CMS IPF DACA Screen shots_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 HBIS Structural Measure Data Collection CMS IPF Data collection paper form_final.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 HBIPS-2 Measure Screen Shot CMS IPF Data collection_screen shots_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Decline to Participate CMS IPF Decline to Participate form_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Extroadinary Circumstance/Waiver Request Form CMS IPF Extraordinary Circumstance Paper Form_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Notice of Participation Screen Shot CMS IPF NoP screen shots_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Notice of Participation CMS IPF NoP_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Vendor Authorization Screen Shot CMS IPF Vendor Auth Screen Shots_final_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Vendor Authorization CMS IPF Vendor Authorization_Paperform_Final.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10432 Withdrawal of Participation CMS IPF Withdrawal form_paper_final.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,200 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 596,200 0 124,389 0 0 471,811
Annual IC Time Burden (Hours) 2,279,200 0 863,767 0 0 1,415,433
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Notification Letter IPFQR_Notification Letter_Aug_26_2012.docx 09/05/2012
Crosswalk CMS IPF Crosswalk.docx 05/28/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.