CMS-10390 Hospice Voluntary Quality Data Submission Form

CMS Voluntary Quality Reporting Program Related to
Section 3004 of the Affordable Care Act

Hospice Quality Data Submission Form
Facility Provider Identification
(Fill in all fields)
Hospice Provider’s Business
Name

[Text field: Enter the legal name of your hospice organization]

Hospice Provider’s Mailing
Address

[Text field: Enter the mailing address of your hospice organization]

Hospice Provider’s Physical
Address
(if different from mailing address)

[Text field: Enter the physical address, if different from your mailing address,
of your hospice organization]

Hospice Provider’s
Business Telephone Number
(10 digits, no dashes or other
characters)

[Numeric field: Enter the business telephone of your hospice organization
during weekdays 8:30 a.m. to 4:30 p.m. Use numerals only, no dashes or
other characters.]

CMS Certification Number
(CCN):
(6 digits)

[Numeric field: Enter the CMS certification number of your hospice
organization Use numerals only, no dashes or other characters.]

National Provider Identifier
(NPI):
(10 digits)

[Numeric field: Enter the NPI of your hospice organization. Use numerals
only, no dashes or other characters.]
[Text field: Enter the contact name from your hospice organization for
questions about this form.]

Hospice Contact for Questions
about this Form: Name,
Phone, E-Mail Address

[Numeric field: Enter the contact phone number from your hospice
organization for questions about this form.]
[Text field: Enter the contact e-mail address from your hospice organization
for questions about this form.]

Voluntary Quality Data for Reporting Period
(October 1, 2011 through December 31, 2011)
Q1. Does your hospice have a QAPI program that includes three or more quality indicators related to
patient care? (Check answer that applies to your program in box to left.)
[Checkbox
for yes]

a. Yes, our Hospice does have a QAPI program that includes three or more
quality indicators related to patient care.

[Checkbox
for no]

b. No, our Hospice does not have a QAPI program that includes at least three
quality indicators related to patient care.

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Q2. How many patient care-related indicators are included in your hospice’s QAPI program? Please
check the appropriate box below. Refer to the instructions sheet for definition and examples of
patient care-related quality indicators.
[Checkbox
for 0]

0 (If this is your answer, SKIP to Q4 below. Do not answer Q3.)

[Checkbox
for 1]

1

[Checkbox
for 2]

2

[Checkbox
for 3 or more]

3 or more

Q3. If your hospice’s QAPI program includes at least one patient care-related quality indicator, list
each indicator (up to 20 indicators) using the form provided below. Select a topic from the
dropdown menu, and then provide details about your indicator and data source. Refer to the
examples and to the instructions sheet for additional information

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Q4. How much time did it take you to complete this voluntary data submission?
[Checkbox for 1 to 5 minutes]

1 to 5 minutes

[Checkbox for 6 to 10 minutes]

6 to 10 minutes

[Checkbox for 11 to 15 minutes]

11 to 15 minutes

[Checkbox for 16 to 20 minutes]

16 to 20 minutes

[Checkbox for 21 to 25 minutes]

21 to 25 minutes

[Checkbox for more than 26 minutes]

More than 26 minutes

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