CMS-10431 Data Accuracy and Completeness Acknowledgement

PPS-exempt Cancer Hospital 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 2015 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 2015. 

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 2015 PCHQR Program requirements.

[ ] Yes, I Acknowledge

CCN ___________________ Hospital Name __________________________________

Name _______________________________ Position ____________________________

Email Address ________________________________________________________________

Date __________________________

Complete and submit the Data Accuracy and Completeness Acknowledgement

Form via email to: [email protected].

Following receipt of the 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 0938-1175. 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; Stop C4-26-05, Baltimore, Maryland 21244-1850.

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