CMS-10432 Data Accuracy and Completeness

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Data Accuracy and Completeness Acknowledgement for FY 2016
(*) indicates required for providers participating in the Inpatient Psychiatric Facility Quality
Reporting Program
I acknowledge that to the best of my ability all of the information reported for this Inpatient
Psychiatric Facility (IPF) Quality Reporting (IPFQR) Program, as required for the Fiscal Year
2016 IPFQR Program requirements, is accurate and complete. This information includes the
following:
• Aggregated data for all required measures
• Current Notice of Participation and QualityNet Security Administrator
I understand that this acknowledgement covers all IPFQR information reported by this inpatient
psychiatric hospital or psychiatric unit (and any data or survey vendor(s) acting as agents on
behalf of this hospital) to CMS and its contractors, for the FY 2016. 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.
I understand that this acknowledgement is required for purposes of meeting any Fiscal Year 2016
IPFQR Program requirements.
[ ] Yes, I Acknowledge*
* CMS Certification Number
* Facility Name
* CEO or Designee Name
* Position
* Email
* Date
Complete and submit the Data Accuracy and Completeness Acknowledgement form using one of
the following options:
•
•
•

Via My QualityNet to the Global Exchange Group “Inpatient Psych QR Support
Contractor”,
Via secure FAX to Program Manager Telligen IPFQR Support (515)-558-5073, or
Via mail to:
Telligen IPFQR Support
1776 West Lakes Parkway
West Des Moines, IA 50266
Attn. Program Manager

DACA FY 2014 Paper Form

Last Updated 2/01/2013

DO NOT SEND THE COMPLETED FORM VIA EMAIL.
Following receipt of the request form, an email 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 0938-1171. The time required to complete this
information collection is estimated to average 5 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.

DACA FY 2014 Paper Form

Last Updated 2/01/2013