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Federal forms, ICRs, and supporting documents

Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 201812-0938-015 · OMB 0938-1022.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

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 IQR Measure Exception Form IPPS_MeasureExceptionForm_CY 2019 Data Collection (July 2018) ff(508)c.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Notice of Participation Form IQR NOP and Public Reporting NOP Text (Apr 2018).(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Reconsideration Request Form QR_Form_APU Reconsideration Request (Apr 2018)FF.(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CAUTI Validation Template FY2021_CAUTI_Validation Template_April 2018.FINAL(508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CDI Validation Template FY2021_CDI_Validation Template_April 2018.FINAL(508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CLABSI Validation Template 1Q18-2Q18 FY2021_CLABSI_Validation Template_April 2018.FINAL(508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 MRSA Validation Template FY2021_MRSA_Validation Template_April 2018.FINAL(508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Review for Reconsideration Request IQR Validation Review Request Form (Apr 2018) ff.(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
Form and Instruction CMS-10210 Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting Hospital Compare Withholding_Footnoting_Request_Form (4.17.2018).ff.(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Data Accuracy and Completeness Form IPPS_DataAccuracyCompletenessAcknowledgement_FY 2020 (Apr 2018)(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 Extraordinary Circumstances Exception Request 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) 2,520,100 0 -1,117,182 0 0 3,637,282
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Index of changes to forms FY 2019 IPPS Final Rule - Index of HIQR Information Collection Forms (7-25-2018).docx 12/14/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.