CMS-10432 Decline to Participate

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Decline to Participate
Agreement
The facility named below agrees to follow procedures for participating in the Inpatient
Psychiatric Facility Quality Reporting (IPFQR) Program as outlined in the federal regulations
found in the Federal Register and is indicating its decision to decline participation.
Each facility must complete the online electronic “Notice of Participation” or the “Decline to
Participate” paper form as outlined 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 2014 or later Inpatient Psychiatric Facility
Quality Reporting Program, a facility that has previously indicated its intent to participate will be
considered an active Patient Psychiatric Facility Quality Reporting Program participant until
such time as the facility submits a withdrawal to CMS.
This information is in compliance with the CMS guidelines for facilities submitting their quality
performance data, facilities must also continue to display quality information for public viewing
as required by section 1886(d)(1)(B)(v) in accordance with paragraph (4) of the Social Security
Act. Before this information is displayed, facilities will be permitted to review their information
as it is recorded. Based on section 1886(d)(1)(B)(v) in accordance with paragraph (4) of the
Social Security Act, for program year beginning with FY 2014, CMS is required to add other
measures that reflect consensus among affected parties. Eligible facilities must follow the
regulations as outlined in the federal regulations and as summarized on the QualityNet Web site.
CMS must publish on CMS.gov the facility’s submitted data for the required measures. Data 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.
Facility’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
using one of the following options:
•
•

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

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 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.