CMS-10432 Data Accuracy and Completeness

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

Data Accuracy and Completeness Acknowledgement (DACA)

for FY 2014 and Subsequent Fiscal Years.

This is required for providers participating in the Inpatient Psychiatric Quality Reporting Program

I acknowledge that to the best of my ability all of the information reported for this Inpatient Psychiatric Facility (IPF) for the Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program, as required for the Fiscal Year 2014 and subsequent fiscal years IPFQR Program requirements, is accurate and complete. This information includes the following:

• Measure sets as defined for the IPFQR Program

• Current Notice of Participation and QualityNet Security Administrator.

I understand that this acknowledgement covers all IPFQR information reported by this IPF (and any data or survey vendor(s) acting as agents on behalf of this facility) to CMS and its contractors for the FY 2014 and subsequent fiscal years.

To the best of my knowledge, this information was collected in accordance with all applicable requirements. I understand that this information is used as the basis for the public reporting of quality of care.

I understand that this acknowledgement is required for purposes of meeting IPFQR Program requirements.

[ ] Yes, I Acknowledge

Name

Position __________________ (Entered by User)

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.