CMS-10250 HOPQDRP Attestation Form

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: ___________________________________