Information Collection

Hospital Outpatient Quality Reporting

IC 217995 under ICR 202410-0938-014 · OMB 0938-1109.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1109 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10250 Hospital Outpatient Quality Reporting Form and Instruction
CMS-10250.HOQR_v18.0_SpecsManual.pdf Instruction
CMS-10250.HOQR_v18.0_SpecsManual.pdf Instruction
CMS-10250 Web Based Data Collection Tool OQR Web Based Measures Data Collection Tool w PRA Notice.docx Form and Instruction
CMS-10250 Web Based Data Collection Tool OQR Web Based Measures Data Collection Tool w PRA Notice.docx Form and Instruction
CMS-10250.OQR_With CMS-10250.OQR_Withdraw Form CMS-10250.OQR_Withdraw Form.docx Form and Instruction
CMS-10250.OQR_With CMS-10250.OQR_Withdraw Form CMS-10250.OQR_Withdraw Form.docx Form and Instruction
CMS-10250 CMS-10250.HOQR ProgramValidationReconForm CMS-10250.HOQR ProgramValidationReconForm.pdf Form and Instruction
CMS-10250 CMS-10250.HOQR ProgramValidationReconForm CMS-10250.HOQR ProgramValidationReconForm.pdf Form and Instruction
CMS-10250 CMS.10250.Extraordinary Circumstances Exemption Request CMS-10250.ECE Request Form.pdf Form and Instruction
CMS-10250 CMS.10250.Extraordinary Circumstances Exemption Request CMS-10250.ECE Request Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital Outpatient Quality Reporting	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10250	Web Based Data Collection Tool	OQR Web Based Measures Data Collection Tool w PRA Notice.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250.OQR_Withdraw Form	CMS-10250.OQR_Withdraw Form	CMS-10250.OQR_Withdraw Form.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10250.HOQR_v18.0_SpecsManual.pdf	Yes	No	Printable Only
Form and Instruction	CMS-10250	CMS-10250.HOQR ProgramValidationReconForm	CMS-10250.HOQR ProgramValidationReconForm.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250	CMS.10250.Extraordinary Circumstances Exemption Request Form	CMS-10250.ECE Request Form.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Beneficiary Database (MBD)	FR Citation: 83 FR 6591

Number of Respondents: 3,350	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	968,150	0	968,150
Annual IC Time Burden (Hours)	54,189,977	53,913,829	276,148
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.