CMS-10431 Data Accuracy and Completeness Agreement

PPS-Exempt Cancer Quality Reporting (PCHQR) Program
Data Accuracy and Completeness Acknowledgement

I acknowledge that, to the best of my ability, all of the information reported for this hospital for
the PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program, as required for the
annual Fiscal Year 2014 PCHQR Program requirements, is accurate and complete. This
information includes the following:
•
•

Measure sets as defined for the PCHQR Program
Current Notice of Participation and QualityNet Security Administrator.

I understand this acknowledgement covers all PCHQR information reported by this hospital
(and any data or survey vendor(s) acting as agents on behalf of this hospital) to the Centers for
Medicare & Medicaid Services (CMS) and its contractors for the FY 2014.
To the best of my knowledge, this information was collected in accordance with all applicable
requirements. I understand that this information is used as the basis for the public reporting of
quality of care and patient assessment of care.
I understand that this acknowledgement is required for purposes of meeting any Fiscal Year
2014 PCHQR Program requirements.
[ ] Yes, I Acknowledge
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.
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.