CMS-10250 HOPQDRP Attestation Form

Submission of Information for the Hospital Outpatient Quality Data Program

CMS-10250.HOPQDRP Attestation Form

Submission of Information for the Hospital Outpatient Quality Data Program

OMB: 0938-1044

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Hospital Outpatient Quality Data Reporting Program (HOPQDRP)

Data Attestation Form



In signing this form, you attest that, to the best of your knowledge, the HOPQDRP Data Feedback reports for outpatient quality measure data submitted by your hospital for the applicable time period have been reviewed by appropriate personnel and it is believed that the data submitted via QualityNet Exchange are accurate and complete for __________________ (example: first calendar quarter 2008)


Hospitals are responsible for submitting complete, accurate, and valid samples. For any and all clinical process and outcome measures, hospitals must follow the sampling guidelines as outlined in the appropriate version of the HOPQDRP Specifications Manual.


Check one (1) of the following:


I attest that the clinical process measures data are complete and accurate.


I do not attest that the data submitted are complete and accurate.


Comments:



Hospital Name: _________________________________________________________


Medicare Provider Number: _______________________________________________


Street Address: ________________________________________________________


City, State, Zip Code: ____________________________________________________


Hospital/Health System CEO (or designee):


Name (please print): ____________________________________________________


Title: _________________________________________________________________


Date: _________________Signature: ___________________________________

File Typeapplication/msword
File TitleReporting Hospital Quality Data for Annual Payment Update (RHQDAPU)
AuthorSheryl Marshall
Last Modified ByCMS
File Modified2008-01-22
File Created2008-01-22

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