CMS-10431 Data Accuracy and Completeness Form

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

FY 2020 Data Accuracy and Completeness Acknowledgement (DACA)

To the best of my knowledge, at the time of submission of this form, all of the information reported for this hospital for participation in the PCHQR Program is accurate and complete. This acknowledgement is for information submitted since the completion of the Fiscal Year (FY) 2020 DACA signed in Calendar Year 2020. This information includes the following:

• Measure data, as defined for the PCHQR Program

• All Program requirements, as defined for the PCHQR Program (e.g., where applicable, chart abstraction and/or sampling)

• Current Notice of Participation

• Active QualityNet Security Administrator

I understand this acknowledgement covers all PCHQR 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. The data submitted in the time frame covered by this DACA are required for purposes of meeting the requirements for FYs 2018, 2019, 2020, and 2021, as specified in the Final Rules governing the PCHQR Program.

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 reporting quality of care and patient assessment of care to the public.

• Yes, I Acknowledge

CMS Certification Number: ____________

Hospital Name: _________________________________________________________________

Name: ____________________________ Position: ___________________________________

Signature: _____________________________________________________________________

Email Address: _________________________________________________________________

Date: _____________________________

Paperwork Reduction Act (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 0938-1175. The expiration date is 01/31/2022. 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.

*****CMS Disclaimer*****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 James Poyer at (410) 786-2261.