CMS-10431 Notice of Participation

PPS-exempt Cancer Hospital Quality Reporting (PCHQR)
Program Notice of Participation
Indicates Required Field
The hospital agrees to follow procedures for participating in the PCHQR Program as
outlined in the federal regulations found in the Federal Register or is indicating its
decision to decline participation.
Each hospital must complete this "PCHQR Notice of Participation" as outlined in the
Federal Register. In an effort to alleviate the burden associated with submitting this
form annually, effective with the PCHQR Notice submitted for participation in FY
2014 or later, a hospital that indicated its intent to participate will be considered an
active PCHQR participant until CMS determines a need to pledge again, or the
hospital submits a withdrawal to CMS.
This information is in compliance with the CMS guidelines for hospitals submitting
their quality performance data in accordance with Section 5001(b) of the Deficit
Reduction Act of 2005. Hospitals must also continue to display quality information
for public viewing as required by section 1866(k)(4) of the Social Security Act. Before
this information is displayed, hospitals will be permitted to review their information
as it is recorded. Eligible hospitals must follow the regulations as outlined in the
federal regulations.
We entities operating under the submitted Provider ID: CCN-XXXXXX
Select participation status...
Agree to participate
Request to be withdrawn from participation
This acknowledgement (to participate or to withdraw) remains in effect until
an electronically signed acknowledgement applying changes has been
entered.
By entering my acknowledgement, I hereby issue this PCHQR Notice of Participation
with the specified direction contained within.
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 XX/XX/XXXX. 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 21244-1650.

By entering this pledge, I agree to:
•
•

Transmit or have data transmitted to CMS; and
Permit my hospital's performance information to be publicly reported.

Date
XX/XX/XXXX 00:00:00

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 XX/XX/XXXX. 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 21244-1650.