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 Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital VPB Review and Corrections Form Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Extraordinary Circumstances Form CMS Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting Request Form for Withholding_Footnoting Data for Public Reporting.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Measure Exception Form CMS IPPS Quality Reporting Programs Measure Exception Form for PC and HAI Data Submission.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Notice of Participation Form Hospital Inpatient Quality Reporting Notice of Participation.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Reconsideration Request Form CMS Quality Reporting Program APU Reconsideration Request Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Review for Reconsideration Request CMS Hospital IQR Program Validation Review for Reconsideration Request Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 VBP Appeal Request Form Hospital Value-Based Purchasing (VBP) Program Appeal Request Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP CMS Independent Review Form Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Educational Review Form CMS Quality Reporting Validation Educational Review Form.pdf Yes Yes Fillable Fileable

Health Public Health Monitoring

 

4,400 0
   
Private Sector 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 17,600 0 0 0 0 17,600
Annual IC Time Burden (Hours) 1,572,443 0 -40,267 0 0 1,612,710
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Summary of Updates on HIQR Collection Forms Summary of HQR Information Collection Forms - FY2021 IPPS Final Rule - HQR PRA Package (1).docx 05/12/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.