Form CMS-10432 IPF Data Accuracy Form

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

Data Accuracy and Completeness Acknowledgement for FY 2020

All fields are required for providers participating in the Inpatient Psychiatric Facility Quality Reporting Program.

I acknowledge that to the best of my ability all of the information reported for this Inpatient Psychiatric Facility (IPF) Quality Reporting (IPFQR) Program, as required for the Fiscal Year 2020 IPFQR Program requirements, is accurate and complete. This information includes the following:

• Aggregated data for all required measures

• Current Notice of Participation and QualityNet Security Administrator

I understand that this acknowledgement covers all IPFQR information reported by this inpatient psychiatric hospital or psychiatric unit (and any data or survey vendor(s) acting as agents on behalf of this hospital) to CMS and its contractors, for the FY 2020 payment determination. To the best of my knowledge, 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.

I understand that this acknowledgement is required for purposes of meeting any Fiscal Year 2020 IPFQR Program requirements.

[ ] Yes, I Acknowledge

CMS Certification Number

Facility Name

CEO or Designee Name

Position

Email

Date

IPFs should complete the form in a fillable PDF format and submit via email to:

[email protected].

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 0938-1171 (Current expiration 07/31/2019). The time required to complete this information collection is estimated to average 5 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 estimate(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, Maryland 21244-1850.

Updated 04/2017 Page 1 of 1