CMS-10394 Public Report Submission Form

Public Report Submission Form

Public Report Submission Form
Complete the applicable fields in Table 1 referencing your most recent public report. If you have any
questions or concerns while completing this form, contact QECP Support.
Table 1: Public Report Submission Form
Category

Item

Public Report Name

[Enter item]

Date Released

[Enter item]

Geographic Region of Public Report

[Enter item]

Regional vs. Provider Identified

[Enter item]

Corrections and Appeals Start Date

[Enter item]

Corrections and Appeals End Date

[Enter item]

Years of QE Medicare Data Included in Public Report

[Enter item]

Measures in Public Report Including Medicare Data

[Enter item]

URL for Website Link to Report

[Enter item]

Status

[Enter item]

Public Report Organization

[Enter item]

Notes

[Enter item]

1