View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Inpatient Psychiatric Facility Quality Reporting Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10432	IPF Data Accuracy Form	CMS IPF DACA Paper Form_FY2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	HBIPS Measures Data Collection Tool	CMS IPF HBIPS Data collection paper form_FY2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Vendor Authorization Form	CMS IPF Vendor Auth_paperform_FY2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Online Data Entry Tool Content for Structural Measures	EHR Pt Experience 2019.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	FY 2019 Non-Measure Data Collection Paper Tool	FY 2020 IPF_NonMeasureData_PprTool_.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	IPF Screen shots	IPF Screen Shots_08_02_2016.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Notice of Participation	IPFQR_NOP_FY2020.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Online Data Entry Tool Content for Web-Based Measure Collection	Screening for Metabolic Disorders collection form FY 2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	TOB IMM Collection Form	TOB IMM collection form FY 2020.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Transitions Measures Collection Form	Transition Measure collection form FY 2019.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	Substance Use Measure Collection	IPF_FY2020 SUB_form.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,684	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	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	1,428,032	0	0	0	0	1,428,032
Annual IC Time Burden (Hours)	4,662,154	0	4,210	0	0	4,657,944
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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