Form CMS-10210 Data Accuracy and Completeness Form

Data Accuracy and Completeness Acknowledgement Form
Provider: ______________________________________________________________
CCN: _________________________________________________________________
NPI: __________________________________________________________________
Submission Period: ______________________________________________________
To the best of my knowledge, at the time of submission, all of the information reported for this hospital
for the Hospital Inpatient Quality Reporting (IQR) Program, as required for the annual Fiscal Year (FY)
2016 Hospital IQR Program, 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);
• Web-based measure (PC-01);
• Current Notice of Participation;
• QualityNet Security Administrator; and
• Electronically Specified Clinical Quality Measures (eCQMs) if submitted.
I understand this acknowledgement covers all Hospital IQR information reported by this hospital (and
any data or survey information reported by vendor(s) acting as agents on behalf of this hospital) to the
Centers for Medicare & Medicaid Services (CMS) and its contractors for the FY 2016 payment update.
To the best of my knowledge, at the time of submission, this information was collected in accordance
with all applicable requirements. I understand this information is used as the basis for the public
reporting of quality of care and patient assessment of care data.
I understand this acknowledgement is required for the purpose of meeting any Fiscal Year 2016
Hospital IQR Program requirements.

Yes, I Acknowledge.
Signature: _____________________________________________________________
Name: ________________________________________________________________
Position: ______________________________________________________________
Date: ____________________________
Instructions for Submission
Please complete and submit this form via email to [email protected] or secure
fax to 877-789-4443.
An email will be sent confirming receipt of the acknowledgement form.
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 0938-1022.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 estimates(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, MD 21244-1650.

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