Information Collection

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

IC 214868 under ICR 202402-0938-013 · OMB 0938-1270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10530 Ambulatory Surgical Center Quality Reporting (ASCQR) Program	Form and Instruction
CMS-10530. 12.0_ASC_Full_Specs_Mnl (1).pdf	Instruction
CMS-10530. 12.0_ASC_Full_Specs_Mnl (1).pdf	Instruction
CMS-10530 Data Collection insruments CMS-10530 ASCQR data submission tool 9-10-21.pdf	Form and Instruction
CMS-10530 Data Collection insruments CMS-10530 ASCQR data submission tool 9-10-21.pdf	Form and Instruction
CMS-10530.CMS Qual CMS-10530.CMS Quality Program ECE Request Form_CY 2024_v CMS-10530.CMS Quality Program ECE Request Form_CY 2024_vFinal.docx	Form and Instruction
CMS-10530.CMS Qual CMS-10530.CMS Quality Program ECE Request Form_CY 2024_v CMS Quality Program ECE Request Form_CY 2025_clean.docx	Form and Instruction
CMS-10530.ASCQR_Wi CMS-10530.ASCQR_Withdraw Form CMS-10530.ASCQR_Withdraw Form.docx	Form and Instruction
CMS-10530.ASCQR_Wi CMS-10530.ASCQR_Withdraw Form CMS-10530.ASCQR_Withdraw Form.docx	Form and Instruction
CMS Quality Program ECE Request Form_CY 2025_redline.docx Redline: ECE Request Form	IC Document

IC Title:

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10530	Data Collection insruments	CMS-10530 ASCQR data submission tool 9-10-21.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10530. 12.0_ASC_Full_Specs_Mnl (1).pdf	Yes	No	Printable Only
Form and Instruction	CMS-10530.CMS Quality Program ECE Request Form_CY	CMS-10530.CMS Quality Program ECE Request Form_CY 2024_vFinal	CMS Quality Program ECE Request Form_CY 2025_clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10530.ASCQR_Withdraw Form	CMS-10530.ASCQR_Withdraw Form	CMS-10530.ASCQR_Withdraw Form.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,057

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,294,592	105,216	1,189,376
Annual IC Time Burden (Hours)	54,491	3,333	51,158
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Redline: ECE Request Form	CMS Quality Program ECE Request Form_CY 2025_redline.docx	07/10/2024

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