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

View Information Collection (IC)

Quality Measures and Procedures for Hospital Reporting of Quality Data
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10210 Data Accuracy and Completeness Form IPPS_Data Accuracy Completeness Acknowledgement (April 2019) (508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital VPB Review and Corrections Form HVBP_Review_and_Corrections_Request_Form_Final_April2018.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Extraordinary Circumstances Form CMS Quality Program ECE Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting Hospital Compare Withholding Footnoting Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Measure Exception Form IPPS Measure Exception Form CY2020 Data (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Notice of Participation Form IQR NOP and PR NOP Text (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Reconsideration Request Form Quality Reporting Reconsideration Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CAUTI Validation Template FY2022_CAUTI_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CDI Validation Template FY2022_CDI_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CLABSI Validation Template 1Q18-2Q18 FY2022_CLABSI_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 MRSA Validation Template FY2022_MRSA_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Review for Reconsideration Request IQR Validation Reconsideration Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 VBP Appeal Request Form HVBP Appeal Request Form Final April2018.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP CMS Independent Review Form HVBP CMS Independent Review Form_April2018_Final.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Educational Review Form Quality Reporting Validation Educational Review Form (Apr 2018)ff(508).pdf Yes Yes Fillable Fileable

Health Public Health Monitoring

 

4,400 0
   
Private Sector Businesses or other for-profits
 
   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 17,600 0 0 0 0 17,600
Annual IC Time Burden (Hours) 1,612,710 0 -907,390 0 0 2,520,100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Summary of Updates on HIQR Collection Forms Summary of HIQR Information Collection Forms - FY2020 IPPS Final Rule - HIQR PRA Package (July 2019).docx 10/28/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.