Information Collection

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

IC 203679 under ICR 202104-0938-013 · OMB 0938-1153.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1153 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10390 Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction
HQRP QM Users Manual V.4_8.07.20_508c_toCMS.pdf	Instruction
HQRP QM Users Manual V.4_8.07.20_508c_toCMS.pdf	Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions_8.07.20_508c_toCMS.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions_8.07.20_508c_toCMS.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_toCMS.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_toCMS.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_toCMS.pdf	Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_toCMS.pdf	Form and Instruction
HISv3 change table_508.pdf Crosswalk	IC Document
HISv3 change table_508.pdf Crosswalk	IC Document

IC Title:

Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10390	Hospice Item Set - Descriptions	CMS-10390 - HQRP Hospice Item Set- Item Descriptions_8.07.20_508c_toCMS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Admissions	CMS-10390 - HQRP HIS Admissions_508c_toCMS.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Discharge	CMS-10390 - HQRP-HIS-v3000-Discharge_508c_toCMS.pdf	Yes	Yes	Fillable Fileable
Instruction			HQRP QM Users Manual V.4_8.07.20_508c_toCMS.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,688

Number of Respondents for Small Entity: 4,046

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	4,688	4,688
Annual IC Time Burden (Hours)	636,312	636,312
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	HISv3 change table_508.pdf	10/23/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.