CMS-10431 Notice of Participation Paper Form

PPS-Exempt Cancer Quality Reporting (PCHQR) Program

Notice of Participation

(*) indicates required for providers participating in the PPS-Exempt Cancer Hospital Quality Reporting Program

Please review the Notice of Participation below:

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

Notice of Participation 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 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 3005 of the Affordable Care Act. 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.

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Request to be withdrawn from participation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.

This acknowledgement (to participate or not to participate or to withdraw) remains in effect until an electronically signed acknowledgement applying changes has been entered.

*Facility Name:

*CEO Signature: *Date:

*CEO Email Address:

Complete and submit the Notice of Participation Agreement form using one of the following options:

• via My QualityNet to the Global Exchange Group “PPS Exempt Cancer Hosp. QR Support ”;

• via secure FAX to Program Manager Telligen PCHQR Support (515)-558-5073, or

• via mail to:

Telligen PCHQR Support

1776 West Lakes Parkway,

West Des Moines, IA 50266

Attn. Program Manager

DO NOT SEND the completed form via e-mail.

Following receipt of the request form, an e-mail acknowledgement will be sent confirming the form has been received.

Paper Form 02/08/2013 Page 2 of 2