CMS-10210 Decline to Participate

Hospital Inpatient Quality Reporting Program

Decline to Participate

Agreement

The hospital named below agrees to follow procedures for participating in the Hospital Inpatient

Quality Reporting (IQR) Program as outlined in the federal regulations found in the Federal Register and is indicating its decision to decline participation.

Each hospital must complete the online electronic “Notice of Participation” or the “Decline to Participate” paper form as outlined in the FY 2013 Reference Checklist on QualityNet and in the federal regulations found in the Federal Register. In an effort to alleviate the burden associated with completing this annually, effective with the Notice of Participation submitted for participation in the FY 2008 or later Hospital IQR Program, a hospital that has previously indicated its intent to participate will be considered an active Hospital IQR Program participant until such time as 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 that do not follow the guidelines as outlined in the federal regulations may receive a reduction of 2.0 percent in their Medicare Annual Payment Update (APU) 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 Social Security 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 Social Security 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 regulations and as summarized in the FY2013 Reference Checklist on QualityNet.

In order to receive the full market basket update, CMS must publish on Hospital Compare the hospital’s submitted data for the required measures. Data aggregated at the hospital level will be provided to the Secretary.

To participate, a hospital must access the online QualityNet Notice of Participation tool.

To DECLINE to participate, the below signature states the signer has read and agrees to the foregoing provisions and the participation decision, and acknowledges same by signing here.

Hospital’s Name _____________________________________________________________

CMS Certification Number (CCN) _______________________________________________

Signature of CEO (or Designee) ________________________________________________

Signer’s Name, Printed or Typed ________________________________________________

Signer’s Title _______________________________________________________________

Date Signed ________________________________________________________________

If declining to participate, submit this completed and signed “Decline to Participate” form directly to your QIO.