HIQR Forms Crosswalk

Form	Notes on Updates
Notice of Participation	No updates/changes to previously submitted form; Form still in use
Data Accuracy and Completeness Acknowledgement	No updates/changes to previously submitted form; Form still in use
Request for Withholding Data from Public Reporting	No updates/changes to previously submitted form; Form still in use
Measure Exception Form	Form resubmitted with updates to allow for exceptions to reporting Perinatal Care (PC) and Emergency Department (ED) measures, in addition to Healthcare-Associated Infection (HAI) measures and to add Hospital Value-Based Purchasing and Hospital-Acquired Condition (HAC) Reduction Programs
Reconsideration Request Form	No updates/changes to previously submitted form; Form still in use
HVBP Review and Corrections Form	No updates/changes to previously submitted form; Form still in use
HVBP Appeals Form	No updates/changes to previously submitted form; Form still in use
Extraordinary Circumstances Extensions/Exemptions Request Form	Form resubmitted with updates to reflect that it will be used across eight quality reporting programs
Validation Review for Reconsideration Request	No updates/changes to previously submitted form; Form still in use
Validation Template for Central Line Associated Bloodstream Infection (CLABSI)	Form updated with revised dates
Validation Template for Catheter-Associated Urinary Tract Infection (CAUTI)	Form updated with revised dates
Validation Template for MRSA Bacteremia (MRSA)	Form updated with revised dates
Validation Template for Clostridium Difficile (CDI)	Form updated with revised dates

Summary of HIQR Information Collection Forms: Updates for the FY 2016 IPPS Proposed Rule

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