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

Hospice Quality Reporting Program (CMS-10390)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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
HIS_UserManualVersion_3.0_February2021.pdf Instruction
HIS_UserManualVersion_3.0_February2021.pdf Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions.pdf Form and Instruction
CMS-10390 Hospice Item Set - Descriptions CMS-10390 - HQRP Hospice Item Set- Item Descriptions.pdf Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf Form and Instruction
CMS-10390 Hospice Item Set - Admissions CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf Form and Instruction
CMS-10390 Hospice Item Set - Discharge CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf Form and Instruction

Information Collection (IC) Details

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: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Admissions	CMS-10390 - HQRP HIS Admissions_508c_8-7-23.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10390	Hospice Item Set - Discharge	CMS-10390 - HQRP-HIS-v3000-Discharge_508c_8-7-23.pdf	Yes	Yes	Fillable Fileable
Instruction			HIS_UserManualVersion_3.0_February2021.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Hospice Item Set (HIS) System	FR Citation: 79 FR 19341

Number of Respondents: 5,640	Number of Respondents for Small Entity: 4,850

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,763,850	2,759,162	4,688
Annual IC Time Burden (Hours)	1,323,883	687,571	636,312
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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