Information Collection

Hospital Outpatient Quality Reporting CY 2016 - CY 2018

IC 217995 under ICR 201508-0938-011 · OMB 0938-1109.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1109 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10250 Hospital Outpatient Quality Reporting CY 2016 - CY 2018 Form and Instruction
CMS-10250 Extroadinary Circumstances Form ExtrdnryCircumForm_121714.pdf Form and Instruction
CMS-10250 Notice of Participation Form OQR Notice of Participation.pdf Form and Instruction
CMS-10250 Validation Review for Reconsideration Request OQR_Form_ValidnReviewReq_7.8.2015.pdf Form and Instruction
CMS-10250 Reconsideration Request Form OQR_ReconReqForm_070815.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital Outpatient Quality Reporting CY 2016 - CY 2018	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10250	Extroadinary Circumstances Form	ExtrdnryCircumForm_121714.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250	Notice of Participation Form	OQR Notice of Participation.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250	Validation Review for Reconsideration Request	OQR_Form_ValidnReviewReq_7.8.2015.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250	Reconsideration Request Form	OQR_ReconReqForm_070815.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,708,260	1,708,260
Annual IC Time Burden (Hours)	1,503,865	1,503,865
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.