Form CMS-10431 Notice of Participation

PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program Notice of Participation

Please review the Notice of Participation below.

PPS-exempt Cancer Hospital Quality Reporting Program Notice of Participation (Pledge Form) - Agreement

The hospital agrees to follow procedures for participating in the PCHQR Program as outlined in the federal regulations found in the Federal Register, or is indicating its decision to decline participation.

Each hospital must complete this "PCHQR Notice of Participation" as outlined in the PCHQR Reference Checklist on 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 PCHQR Notice submitted for participation in FY 2014 or later, a hospital that indicated its intent to participate will be considered an active PCHQR participant until CMS determines a need to pledge again, or the hospital submits a withdrawal to CMS.

This information is in compliance with the CMS guidelines for hospitals submitting their quality performance data in accordance with Section 5001(b) of the Deficit Reduction Act of 2005. Hospitals must also continue to display quality information for public viewing as required by section 1866(k)(4) of the Social Security Act. Before this information is displayed, hospitals will be permitted to review their information as it is recorded. Eligible hospitals must follow the regulations as outlined in the federal regulations and as summarized in the PCHQR Reference Checklist on QualityNet.

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	 Request to be withdrawn from participation.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.