CMS-10210 IQR Notice of Participation Form

Hospital Inpatient Quality Reporting Notice of Participation
Please Note: A collection tool available via the QualityNet Secure Portal allows hospitals to enter their Notice of
Participation, Contacts, and Campuses. To access the collection tool, in the Manage Notice of Participation
section on the My Tasks screen, select the “View/Edit Notice of Participation, Contacts, Campuses” link. This
document is a representation of the text contained in the Hospital Inpatient Quality Reporting Notice of
Participation, as well as the Optional Public Reporting Notice of Participation, and is for reference
purposes only.

Hospital Inpatient Quality Reporting Notice of Participation Text
Hospital Inpatient Quality Reporting Program Notice of Participation (Pledge Form) - Agreement

The hospital agrees to follow procedures for participating in the Hospital Inpatient Quality Reporting (IQR)
Program as outlined in the Code of Federal Regulations at 42 CFR 412.140, or is indicating its decision to
decline participation. Each hospital must complete this “Hospital Inpatient Quality Reporting Notice of
Participation” as outlined in 42 CFR 412.140(a)(3). In an effort to alleviate the burden associated with
submitting this form annually, effective with the Hospital IQR Notice submitted for participation in FY 2008 or
later, a hospital that indicated its intent to participate will be considered an active Hospital IQR participant until
the Centers for Medicare & Medicaid Services (CMS) determines a need to pledge again, or the hospital submits
a withdrawal notice to CMS.
Hospitals paid under the Inpatient Prospective Payment System (IPPS) that do not follow the Hospital IQR
Program procedures and do not meet all program requirements may receive a reduction in their Medicare
Annual Payment Update (APU) for the applicable fiscal year (also known as the Market Basket Update). In
order to avoid the reduction in their APU, hospitals must also display quality information for public viewing as
required by section 1886(b)(3)(B)(viii)(VII) of the Social Security Act, currently published on Hospital
Compare. Before this information is displayed, hospitals will be permitted to review their information as it is
recorded. Eligible hospitals must follow the regulations as outlined in the Federal Register and Code of Federal
Regulations.
A hospital’s choice of participating in the Hospital IQR Program for APU may affect eligibility for the Hospital
Value-Based Purchasing (VBP) Program. Agreeing to participate in the Hospital IQR Program and meeting all
of the applicable program requirements are two of the requirements to be eligible to participate in the Hospital
VBP Program. It is important to note that non-participation in or withdrawal from the Hospital IQR Program
will exclude a hospital from eligibility for the Hospital VBP Program pursuant to section 1886(o)(1)(C)(ii)(I) of
the Social Security Act.
* We entities operating under the submitted CMS Certification Number (CCN):

This acknowledgement (to participate or not to participate or to withdraw) remains in effect until an
electronically signed acknowledgement applying changes has been entered.
*
By entering my acknowledgement, I hereby issue this Hospital IQR Notice of Participation with the
specified direction contained within.

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Optional Public Reporting Notice of Participation Text
NOTE: CMS allows hospitals to submit optional quality measures that can be publicly reported and are not
required for payment determinations under the Hospital Inpatient Quality Reporting Program or other CMS
hospital quality programs. In order to have the opportunity to submit, preview, and publish the optional
measures, the following Optional Public Reporting Notice of Participation is necessary.
By entering this pledge, I agree to:
•
•

Transmit or have data transmitted to CMS and/or the Clinical Data Warehouse; and
Permit my hospital’s performance information to be publicly reported beginning with discharges for the
calendar year quarter indicated below:

*QUARTER:
*YEAR: 20_______

I understand that:
•
•
•
•

The hospital will have at least 30 days to preview measure performance information before the data are
made public.
The hospital may be able to withhold a measure or measures prior to their posting.
The hospital may withdraw from this effort at any time.
This pledge will remain in force and cover current and future measures or measurement sets.

*We entities operating under the submitted CMS Certification Number (CCN):

This acknowledgement (to participate or to withdraw) remains in effect until an electronically signed
acknowledgement applying changes has been entered.
*
By entering my acknowledgment, I hereby issue this Optional Public Reporting Notice of Participation
with the specified direction contained within.

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 (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.

Updated April 2019

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