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 2. Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA)_vFINAL(508)ff (1).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital VPB Review and Corrections Form 7. Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form_vFINAL(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Extraordinary Circumstances Form 6. CMS Quality Program ECE Request Form_CY 2024_vFINAL(508)_ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting 3. Care Compare Withholding Footnoting Request Form_CY 2025_vdFINAL(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Notice of Participation Form 1. Hospital Inpatient Quality Reporting Notice of Participation_vFINAL(508)_ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Reconsideration Request Form 4. CMS Quality Reporting Program APU Reconsideration Request Form_vFINAL(508)_ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Review for Reconsideration Request 5. CMS Hospital IQR Program Validation Review for Reconsideration Request Form_vFINAL(508)_ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 VBP Appeal Request Form 8. Hospital Value-Based Purchasing (VBP) Program Appeal Request Form_vFINAL(508)_ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP CMS Independent Review Form 9. Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form_vFINAL(508)_ff (1).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Educational Review Form 12. HQR_ValEdReviewForm_01_2025_vFINAL(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Maternal Morbidity Structural Measure 10. Maternal Morbidity Structural Measure_vFINAL(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Population and Sampling 11. Population and Sampling_vFINAL(508) (1).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital Inpatient Quality Reporting Program Denominator Declaration 13. Denominator Declaration_vFINAL(508)_ (1).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 THA/TKA Patient-Reported Outcome-based Performance Measure 14. THA_TKA PRO-PM_vFINAL(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Social Drivers of Health Structural Measures 15. SDOH_vFINAL(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital Commitment to Health Equity 16. HCHE_vFINAL(508).pdf Yes Yes Fillable Fileable

Health Public Health Monitoring

 

4,500 1,135
   
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 18,000 0 0 0 0 18,000
Annual IC Time Burden (Hours) 2,283,878 0 -3,099 0 0 2,286,977
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 - FY2025 IPPS Final Rule - HQR PRA Package.docx 06/13/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.