Track Chage - Data Accuracy and Completeness Acknowledgement (DACA)

Inpatient Psychiatric Facility Quality Reporting Program
Data Accuracy and Completeness Acknowledgement (DACA)
Please Note: A data collection tool available within the Hospital Quality Reporting system via
the Hospital Quality Reporting Secure Portal allows hospitals to complete and submit their
DACA. This document is a representation of the text contained in the DACA and is for reference
purposes only.
The DACA is an annual requirement for providers participating in the Hospital IQR, IPFQR, and
PCHQR Programs to electronically acknowledge that the data submitted to these programs by
or on behalf of the providers are accurate and complete to the best of their knowledge.

Data Accuracy and Completeness Acknowledgement (DACA)
I acknowledge that to the best of my ability all of the information reported for the Inpatient
Psychiatric Facility (IPF) Quality Reporting (IPFQR) Program, as required for the Fiscal Year
2024 2028 IPFQR Program requirements is accurate and complete. This information includes
the following:




Aggregate data for all required measures
Non-measure data
Current Notice of Participation

I understand that the acknowledgement covers all IPFQR information reported by this inpatient
psychiatric hospital or psychiatric unit (and any data vendor(s) acting as agents on behalf of this
IPF) to CMS and its contractors for the FY 2025 2028 payment determination year. To the best
of my knowledge, this information was collected in accordance with all applicable requirements.
I understand that this information is used as the basis for the public reporting of quality of care.
I understand that this acknowledgement is required for purposes of meeting any Fiscal Year
2024 2028 IPFQR Program requirements.

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 0938-117 (Expires 08/31/2025). 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 suggestion for improving this form, please write to CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

CMS Disclosure Statement
Please do not send applications, claims, payments, medical records, or any documents
containing sensitive information to the PRA Clearance Office. Please not that any
correspondence not pertaining to the information collection burden approved under the

Inpatient Psychiatric Facility Quality Reporting Program
Data Accuracy and Completeness Acknowledgement (DACA)
associated OMB control number located on this form will not be reviewed, forwarded, or
retained. If you have questions or concerns regarding where to submit your documents, please
contact the iPFQR Support Contractor at (844) 472-4477.

Position
Ex. Administrator, Director, etc.
I confirm that the informaƟon I have submiƩed is accurate and complete, to the best of my
knowledge.

Sign

Cancel

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 09381171 (Expires 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, MD 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or
any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number

Inpatient Psychiatric Facility Quality Reporting Program
Data Accuracy and Completeness Acknowledgement (DACA)
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to
submit your documents, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor at (844) 472-4477.