Inpatient Psychiatric Facility Quality Reporting Program

Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1171 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10432 Inpatient Psychiatric Facility Quality Reporting Program Form
CMS-10432 PIX Survey PIX _ CMS v2.pdf Form
CMS-10432 PIX Survey PIX _ CMS v2.pdf Form
CMS-10432 • IPFQR Program Data Entry Screen Shots (includes NOP, D IPFQR Program Data Entry Screen Shots_July 2023.pdf Form and Instruction
CMS-10432 • IPFQR Program Data Entry Screen Shots (includes NOP, D IPFQR Program Data Entry Screen Shots_July 2023.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Inpatient Psychiatric Facility Quality Reporting 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10432	PIX Survey	PIX _ CMS v2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10432	• IPFQR Program Data Entry Screen Shots (includes NOP, DACA, and Vendor Authorization Forms)	IPFQR Program Data Entry Screen Shots_July 2023.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Beneficiary Database (09-70-0536)	FR Citation: 71 FR 70396

Number of Respondents: 1,596	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,843,012	4,788	12,838,224
Annual IC Time Burden (Hours)	2,713,065	800	2,712,265
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.