Ambulatory Surgical Center Quality Reporting (ASCQR) Program

Ambulatory Surgical Center Quality Reporting Program (CMS-10530)

Documents and Forms

Document Name Document Type
Form CMS-10530 Ambulatory Surgical Center Quality Reporting (ASCQR) Program Form and Instruction
CMS-10530.ASC_v14.0_SpecsManual.pdf Instruction
CMS-10530.ASC_v14.0_SpecsManual.pdf Instruction
CMS-10530 Data Collection insruments CMS-10530 ASCQR data submission tool 9-10-21.pdf Form and Instruction
CMS-10530 Data Collection insruments CMS-10530 ASCQR data submission tool 9-10-21.pdf Form and Instruction
CMS-10530.ASCQR_Wi CMS-10530.ASCQR_Withdraw Form CMS-10530.ASCQR_Withdraw Form.docx Form and Instruction
CMS-10530.ASCQR_Wi CMS-10530.ASCQR_Withdraw Form CMS-10530.ASCQR_Withdraw Form.docx Form and Instruction
CMS-10530 Centers for Medicare & Medicaid Services (CMS) Quality P CMS-10530.ECE Request Form.pdf Form and Instruction
CMS-10530 Centers for Medicare & Medicaid Services (CMS) Quality P CMS-10530.ECE Request Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Ambulatory Surgical Center Quality Reporting (ASCQR) 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10530	Data Collection insruments	CMS-10530 ASCQR data submission tool 9-10-21.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10530.ASCQR_Withdraw Form	CMS-10530.ASCQR_Withdraw Form	CMS-10530.ASCQR_Withdraw Form.docx	Yes	Yes	Fillable Fileable
Instruction			CMS-10530.ASC_v14.0_SpecsManual.pdf	Yes	No	Printable Only
Form and Instruction	CMS-10530	Centers for Medicare & Medicaid Services (CMS) Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form	CMS-10530.ECE Request Form.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,475	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	1,145,600	-148,992	1,294,592
Annual IC Time Burden (Hours)	330,169	275,678	54,491
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.