CMS-10210 Notice of Participation

Reporting Hospital Quality Data for Annual Payment Update

Notice of Participation

For FY 2008 and Forward

We agree to follow the procedures for participating in the Reporting Hospital Quality Data Annual Payment Update (RHQDAPU) program as outlined in the Federal Register.

All hospitals must complete this revised RHQDAPU Notice of Participation form and send to their Quality Improvement Organization (QIO) as outlined in the RHQDAPU Reference Checklist on QualityNet.org and in the Federal Register. In an effort to alleviate the burden associated with submitting this form annually, effective with the form submitted for participation in FY 2008 RHQDAPU, in future years, a hospital that has previously indicated its intent to participate will be considered an active RHQDAPU participant until such time as the hospital submits a withdrawal form 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 that do not follow the guidelines as outlined in the Federal Register may receive a reduction of 2.0 percent in their Medicare Annual Payment Update for the applicable fiscal year. In order to avoid the reduction in their Annual Payment Update, hospitals must also continue to display quality information for public viewing as required by section 1886(b)(3)(B)(viii)(VII) of the Act. Before this information is displayed hospitals will be permitted to review their information as it is recorded. Based on section 1886(b)(3)(B)(viii)(V) of the Act, for payments beginning with FY 2008, CMS is required to add other measures that reflect consensus among affected parties. Eligible hospitals must follow the regulations as outlined in the Federal Register and as summarized in the RHQDAPU Reference Checklist on QualityNet.org.

All hospitals receiving the full market basket update will have published data for the applicable quarters, for all the required measures for the coinciding publications for which they have data. Data aggregated at the hospital level will be provided to the Secretary.

• We agree to participate (complete entire form)

• We do not agree to participate (complete entire form)

Note: To improve the transparency and usefulness of Hospital Compare, for Fiscal Year 2008 and subsequent years, hospitals are required to report the name and address of each hospital that shares the same Medicare Provider Number. For multiple campuses that share the same Medicare Provider Number, submit page 2 of this Pledge form.

Quality Improvement Organization:

Hospital Name: Medicare Provider Number:

Check One: Single Campus: ____ Multiple Campuses: ____ (If Multiple Campus - complete Page two)

National Provider Identifier: (NPI): ____________________ (If more than one NPI, complete Page two)

Street Address:

City, State, Zip Code:

Hospital CEO (or designee) Name (please print):

Hospital CEO (or designee) E-mail Address:

Hospital CEO (or designee) Telephone Number:

Title: Signature Date:

Signature: CEO/Designee Initials:

Please identify your hospital’s point of contact for hospital reporting activities:

Name (please print):

Title: E-mail:

Telephone: Fax:

Reporting Hospital Quality Data for Annual Payment Update

Notice of Participation

For FY 2008 and Forward

Medicare Provider Number:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Campus Name:

Campus Address:

Additional NPI Numbers: This includes independent entities or departments

within the hospital not independent practitioners or individuals.

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