Crosswalk

IPFQR PRA Package

Crosswalk Summary of IPFQR Collection Forms

Form	Notes
HBIPS measure data collection form	Form reflects minor changes to contact information
EHR & Patient Experience data collection form	Newly proposed measures
TOB & IMM data collection form	Newly proposed measures
SUB-1 data collection form	Form reflects minor changes to contact information
Vendor authorization form	Form reflects minor changes to contact information
Notice of Participation Agreement	Form reflects minor changes to contact information, as well as the addition of an option for IPFs to indicate their intent not to participate or withdraw from the Program
Data Accuracy Acknowledgement	Form reflects minor changes to contact information
Extraordinary circumstances exception form	This form has been revised from last year and will be submitted with IQR PRA package.
Reconsideration request form	This form has been revised from last year and will be submitted with IQR PRA package.

Last revised on 4/21/2014