CMS-10432 Vendor Authorization Form

Inpatient Psychiatric Facility Quality Reporting Program
Vendor Authorization Form
All fields are required.
Provider Name

CCN

Address

Telephone

Select One:
[ ] Add New Vendor Authorization

[ ] Edit Vendor Authorization

Vendor Name

Vendor ID

Address

Telephone

Contact Name

FAX

Enter dates for which this vendor is authorized to submit data on your behalf. Enter “End” dates only if you intend
to discontinue authorization for this vendor for those dates. Otherwise, leave “End” dates blank. Carefully review
the information you have entered to verify the new vendor data.
This Vendor is authorized for the following Measures set(s):
Measure
Set

Discharge
Start Date

Discharge
End Date

Data Transmission
Start Date

Data Transmission
End Date

IPF
(Hospital Name)
authorizes (Vendor)
to enter/transmit data for the specified dates. The vendor agrees to enter/transmit data for all payers via QualityNet. The
data collected has also met the CMS standard protocols and transmission requirements. The vendor ensures that all of its
data collection and transmission activities are in accordance with HIPAA regulatory requirements regarding security and
privacy. The authorization remains in effect for the specified vendor until dates are entered to end the authorization.
Please confirm your changes to this vendor’s authorization. CMS requires that you confirm the changes you have made
to the vendor authorization to submit data on your facility’s behalf. Please indicate your confirmation by signing below.
On behalf of my facility, I approve this vendor to transmit our facility quality of care data.

Hospital Representative Name

Updated 04/2014

Hospital Representative Signature

Date

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Inpatient Psychiatric Facility Quality Reporting Program
Vendor Authorization Form
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: MM/DD/YYYY). 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 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 04/2014

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