CMS-10210 Hospital Commitment to Health Equity

Hospital Inpatient Quality Reporting Program
Hospital Commitment to Health Equity
Please Note: A data collection tool available within the Hospital Quality Reporting system via the Hospital Quality
Reporting Secure Portal allows hospitals to complete and submit their Hospital Commitment to Health Equity data. This
document is a representation of the text contained in the measure data form and is for reference purposes only.

Hospital Inpatient Quality Reporting Program
Hospital Commitment to Health Equity
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 0938-1022 (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, MD 21244-1850. ****CMS Disclosure**** 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 the Inpatient Value, Incentives, and
Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.