CMS-10432 Notice of Participation

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

Notice of Participation

Please review the Notice of Participation below.

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

Notice of Participation Agreement

The Inpatient Psychiatric Facility (IPF) agrees to follow procedures for participating in the IPFQR Program as outlined in the federal regulations found in the Federal Register, or is indicating its decision to decline participation. The IPF understands that participation in the IPFQR Program is voluntary for the applicable fiscal year.

Each IPF must complete this " IPFQR Notice of Participation" (IPFQR Notice) as outlined in the IPFQR QualityNet and in the federal regulations found in the Federal Register. In an effort to alleviate the burden associated with submitting this form annually, effective with the IPFQR Notice submitted for participation in FY 2014 program year or later, an IPF that indicated its intent to participate will be considered an active IPFQR Program participant until CMS determines a need to resubmit the IPFQR Notice, or the IPF submits a request for withdrawal to CMS.

This information is in compliance with the CMS guidelines for IPFs submitting their quality performance data in accordance with section 1886(s)(4) of the Social Security Act. Pursuant to section 1886(s)(4)(E) of the Act, IPFs agreeing to participate in the IPFQR Program will have their data publicly displayed on the CMS’ website after being afforded the opportunity to review their data.

We entities operating under the submitted Provider ID: _______________

	 Agree to participate.
	 Do not agree to participate.
	 Request to be withdrawn from participation.

By entering this pledge, I agree to:

(1) Transmit or have data transmitted to CMS and/or the QIO Clinical Warehouse; and

(2) Permit my hospital’s performance information to be publicly reported.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX . The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.