Form CMS-10210 Data Accuracy and Completeness Acknowledgemenmt

Data Accuracy and Completeness Acknowledgement

I acknowledge that, to the best of my ability, all of the information reported for this hospital for the Hospital Inpatient Quality Reporting (IQR) Program, as required for the annual Fiscal Year 2015 Hospital IQR Program requirements, is accurate and complete.  This information includes the following:

• Chart Abstracted measure sets;

• Initial patient population and sample counts;

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey;

• Structural Measures;

• Healthcare Associated Infection measure(s) reported using the National Healthcare Safety Network (NHSN); and

• Current Notice of Participation and QualityNet Security Administrator. 

I understand this acknowledgement covers all Hospital IQR 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 payment update

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 Hospital IQR Program requirements.

[ ] Yes, I Acknowledge

Name _________________________________________

Position _______________________________________

Date___________________________________________