CMS-10432 Withdrawal of Participation

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
WITHDRAWAL OF PARTICIPATION
This form must be completed and mailed or faxed to your Inpatient Psychiatric Facility Quality
Reporting Support Contractor contact if your facility wants to withdraw from participation.
Our facility is withdrawing from participation in Inpatient Psychiatric Facility Quality Reporting
(IPFQR) at this time. Based on this withdrawal, it is our understanding that our facility will not
be listed as a participant on the CMS.gov website.
Required fields marked with an asterisk (*).
*Facility Name

*CMS Certification Number (CCN)

*City, State, ZIP Code:

Facility/Health System CEO (or designee):

*Name (please print):

*Title:

*Date:

02/2013

*Signature:

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Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
WITHDRAWAL OF PARTICIPATION
If withdrawing from the IPFQR program, submit this completed and signed “Withdrawal
of Participation” 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

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-02/13-009

02/2013

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