Form CMS-10250 Notice of Participation

Hospital Outpatient Quality Data Reporting Program (HOPQDRP)

Notice of Participation

For CY 2009 payment and Forward

We agree to follow the procedures for participating in the Hospital Outpatient Data Reporting Program (HOP QDRP) program as outlined in the Federal Register.

All hospitals must complete a HOPQDRP Notice of Participation form and send to the designated contractor as outlined in the HOPQDRP Reference Checklist available on QualityNet.org and in the Federal Register. To alleviate the burden associated with submitting a notice of participation form annually, effective with the form submitted for participation in the HOPQDRP affecting CY 2009 payment, a hospital that has previously indicated its intent to participate will be considered an active HOPQDRP participant until such time as the hospital submits a withdrawal form to the Centers for Medicare and Medicaid Services (CMS).

This information is in compliance with the CMS guidelines for hospitals submitting their quality performance data in accordance with Section 109(a) of the Tax Relief and Health Care Act of 2006. Hospitals that do not follow the guidelines as outlined in the Federal Register may receive a reduction of 2.0 percent in their Medicare Annual Payment Update for the applicable calendar year. In the event that the CMS makes such data available to the public for viewing, to avoid the reduction in their annual payment update factor, hospitals must also continue to display quality information for public viewing as required by section 1833(t)(17)(E) of the Act. Before this information is displayed hospitals will be permitted to review their information as it is recorded. Eligible hospitals must follow the regulations as outlined in the Federal Register and as summarized in the HOPQDRP Reference Checklist on QualityNet.org.

Hospitals will be provided the opportunity to review their hospital quality performance data to be made available for public viewing before these data are released. All such data will be aggregated as determined by the CMS.

• We agree to participate (complete entire form)

• We do not agree to participate (complete entire form)

Note: To improve the transparency and usefulness of publicly available quality performance data, for Calendar Year 2009 and subsequent years, hospitals are required to report the name and address of each hospital that shares the same Medicare Provider Number (MPN). For multiple campuses* that share the same MPN, submit page 2 of this Pledge form.

Hospital Name: Medicare Provider Number:

Check One: Single Campus*: ____ Multiple Campuses*: ____ (If Multiple Campus* - complete Page two)

National Provider Identifier: (NPI): ____________________ (If more than one NPI, complete Page two)

Street Address:

City, State, Zip Code:

Hospital CEO (or designee) Name (please print):

Hospital CEO (or designee) E-mail Address:

Hospital CEO (or designee) Telephone Number:

Title: Signature Date:

Signature: CEO/Designee Initials:

Please identify your hospital’s point of contact for hospital reporting activities:

Name (please print):

Title: E-mail:

Telephone: Fax:

Hospital Outpatient Quality Data Reporting Program (HOPQDRP)

Notice of Participation

For CY 2009 and Forward

If additional facilities, please copy this page

Medicare Provider Number:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

* Campus means the physical area immediately adjacent to the

provider's main buildings, other areas and structures that are

not strictly contiguous to the main buildings but are located

within 250 yards of the main buildings, and any other areas

determined on an individual case basis, by the HCFA regional

office, to be part of the provider's campus. (42CFR413.65)

Additional NPI Numbers: This includes independent entities or departments

within the hospital not independent practitioners or individuals.

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