Information Collection

Hospital Outpatient Quality Reporting CY 2016 - CY 2018

IC 217995 under ICR 201603-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

Hospital Outpatient Quality Reporting CY 2016 - CY 2018

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,331,486	2,331,486
Annual IC Time Burden (Hours)	3,056,717	3,056,717
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.