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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10250 Hospital Outpatient Quality Reporting	Form and Instruction
Form CMS-10250 Web Based Data Collection Tool Hospital Outpatient Quality Reporting	Form and Instruction
Form CMS-10250.OQR_With CMS-10250.OQR_Withdraw Form Hospital Outpatient Quality Reporting	Form and Instruction
Form CMS-10250 CMS-10250.HOQR ProgramValidationReconForm Hospital Outpatient Quality Reporting	Form and Instruction
Form CMS-10250 CMS.10250.Extraordinary Circumstances Exemption Request Form 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10250	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250.OQR_Withdraw Form	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only
Form and Instruction	CMS-10250	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10250	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].