Information Collection

Submission of Information for the Hospital Outpatient Quality Data Reporting Program

IC 188916 under ICR 200904-0938-012 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10250 Submission of Information for the Hospital Outpatient Quality Data Reporting Program	Form and Instruction
CMS-10250 CMS-10250.HOPQDRP Attestation Form with Disclosure State CMS-10250.HOPQDRP Attestation Form with Disclosure Statement.doc	Form and Instruction
CMS-10250 CMS-10250.Notice of Participation with Disclosure Statem CMS-10250.Notice of Participation with Disclosure Statement.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 419.43(h)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10250	CMS-10250.HOPQDRP Attestation Form with Disclosure Statement	CMS-10250.HOPQDRP Attestation Form with Disclosure Statement.doc		Yes	No	Fillable Fileable
Form and Instruction	CMS-10250	CMS-10250.Notice of Participation with Disclosure Statement	CMS-10250.Notice of Participation with Disclosure Statement.doc		Yes	No	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 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
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

table that charts IC Documents
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.