Form CMS-10210 Data Accuracy and Completeness Form

Hospital Inpatient Quality Reporting (IQR) Program
Data Accuracy and Completeness Acknowledgement (DACA) Text
Please Note: A collection tool available on the QualityNet Secure Portal allows hospitals to
complete and submit their DACA. This document is a representation of the text contained in the
DACA and is for reference purposes only.
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
Payment Year (PY) 2019 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 data
• Structural Measures
• Healthcare-Associated Infection (HAI) Measures reported using the National Healthcare
Safety Network (NHSN)
• Influenza Vaccination Among Healthcare Personnel (HCP) Measure reported using
NHSN
• Web-Based Measure (PC-01)
• Electronic Clinical Quality Measures (eCQMs)
• Current Notice of Participation
• QualityNet Security Administrator
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 PY
2019 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 that this information is used as the
basis for the public reporting of quality of care and patient assessment of care data.
I understand that this acknowledgement is required for the purpose of meeting any PY 2019
Hospital IQR Program requirements.

[ ] Yes, I Acknowledge.
Name _________________________________________
Position _______________________________________
Date ___________________________________________
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. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved
under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact the Hospital IQR Support Contractor
at (844) 472-4477. Expiration Date: XX-XX-XXXX

March 2017