Information Collection

Submission of Information for the Hospital Outpatient Quality Data Program

IC 183593 under ICR 200810-0938-018 · OMB 0938-1044.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1044 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10250 Submission of Information for the Hospital Outpatient Quality Data Program Form and Instruction
CMS-10250 CMS-10259. HOPQDRP Attestation Form CMS-10250.HOPQDRP Attestation Form.doc Form and Instruction
CMS-10250 CMS-10250. Notice of Participation CMS-10250.Notice of Participation.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Submission of Information for the Hospital Outpatient Quality Data Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 419.43(h)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10250	CMS-10259. HOPQDRP Attestation Form	CMS-10250.HOPQDRP Attestation Form.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250	CMS-10250. Notice of Participation	CMS-10250.Notice of Participation.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	14,000	14,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.