Form CMS-10210 Data Accuracy and Completeness Form

Hospital Quality Reporting
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 to the Centers for Medicare & Medicaid Services (CMS) 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
• 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 Perinatal care measure (PC-01)
• Electronic clinical quality measures (eCQMs)
• Current Notice of Participation
• QualityNet Security Administrator
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 experience of care data, for annual
payment updates under the Hospital Inpatient Quality Reporting Program, and for value-based
payment adjustments under the Hospital-Acquired Condition Reduction Program and the
Hospital Value-Based Purchasing Program.
I understand this acknowledgement covers all inpatient hospital information reported by this
hospital (and any data or survey information reported by any vendors acting as agents on behalf
of this hospital) to CMS and its contractors.

[ ] 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 09381022 (Expires xx/xx/xxxx). 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, MD 21244-1850. ****CMS Disclosure**** 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 Inpatient Value, Incentives, and Quality Reporting Outreach and
Education Support Contractor at (844) 472-4477.

April 2019