PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program
WITHDRAWAL OF PARTICIPATION
This form must be completed and mailed or faxed to your PPS-exempt Cancer Hospital Quality Reporting Support Contractor contact if your facility wants to withdraw from participation in the PPS-exempt Cancer Hospital Quality Reporting Program.
Our facility is withdrawing from participation in PPS-exempt Cancer Hospital Quality Reporting at this time. Based on this withdrawal, it is our understanding that our facility will not be listed as a participant on the CMS.gov web site.
Facility Name:
CMS Certification Number (CCN)
City, State, ZIP Code:
Facility/Health System CEO (or designee):
Name (please print):
Title:
Date: Signature: _____
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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |