CMS-10431 Data Accuracy and Completeness Form

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
FY 2021 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) 2021
DACA signed in Calendar Year 2021. This information includes the following:
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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 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 09381175. The expiration date is 12/31/2022. 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.