CMS-10431 Data Accuracy and Completeness Form

PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program

Data Accuracy and Completeness Acknowledgement

I acknowledge that, to the best of my ability, all of the information reported for this hospital for the PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program, as required for the annual Fiscal Year 2020 PCHQR Program requirements, is accurate and complete.  This information includes the following:

• Measure sets as defined for the PCHQR Program

• Current Notice of Participation and QualityNet Security Administrator. 

I understand this acknowledgement covers all PCHQR information reported by this hospital (and any data or survey vendor(s) acting as agents on behalf of this hospital) to the Centers for Medicare & Medicaid Services (CMS) and its contractors for the FY 2020. 

To the best of my knowledge, this information was collected in accordance with all applicable requirements.  I understand that this information is used as the basis for the public reporting of quality of care and patient assessment of care. 

I understand that this acknowledgement is required for purposes of meeting any Fiscal Year 2020 PCHQR Program requirements.

[ ] Yes, I Acknowledge

CCN ___________________ Hospital Name __________________________________

Name _______________________________ Position ____________________________

Email Address ________________________________________________________________

Date __________________________

Complete and submit the Data Accuracy and Completeness Acknowledgement Form via email to: PCHQualityReporting@hcqis.org.

Following receipt of the form, an email acknowledgement will be sent confirming the form has been received.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1175 and expires XX/XX/XXXX. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact James Poyer at (410) 786-2261.

PCHQR Program 2/20/2017 Page 1 of 1