CMS-10432 Vendor Authorization

Inpatient Psychiatric Facility Quality Reporting Program
Vendor Authorization Form
Required fields are marked with an asterisk (*).
*CCN

*Provider Name

*Address

*Telephone

[ ] *Add New Vendor Authorization

[ ] *Edit Vendor Authorization

*Vendor Name

*Vendor ID

*Address

*Telephone

*Contact Name

*FAX

Enter dates for which this vendor is authorized to submit data on your behalf. Enter “End” dates only if you intend to
discontinue authorization for this vendor for those dates. Otherwise, leave “End” dates blank. Carefully review the
information you have entered to verify the new vendor data.
*This Vendor is authorized for the following Measures set(s):

Measure
Set

*Discharge

*Discharge

*Data Transmission

*Data Transmission

Start Date

End Date

Start Date

End Date

IPF

*(Hospital Name)
authorizes *(Vendor)
to enter/transmit data for the specified dates. The vendor agrees to enter/transmit data for all payers via QualityNet. The
data collected has also met the CMS standard protocols and transmission requirements. The vendor ensures that all of its
data collection and transmission activities are in accordance with HIPAA regulatory requirements regarding security and
privacy. The authorization remains in effect for the specified vendor until dates are entered to end the authorization.
Please confirm your changes to this vendor’s authorization. CMS requires that you confirm the changes you have made to
the vendor authorization to submit data on your facility’s behalf. Please indicate your confirmation by signing below.
On behalf of my facility, I approve this vendor to transmit our facility quality of care data.

*Hospital Representative Name
02/2013

*Hospital Representative Signature

*Date
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Inpatient Psychiatric Facility Quality Reporting Program
Vendor Authorization Form
Please send completed forms to the Inpatient Psychiatric Support Contractor:
•
•
•

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

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 S TATEMENT
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

This material was prepared by Telligen, Inpatient Psychiatric Facilities Quality Reporting Program Support Contractor, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 10SoW-IA-IPFQR-02/13-006

02/2013

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