Information Collection

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

IC 214868 under ICR 202601-0938-003 · OMB 0938-1270.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10530 Data Collection insruments Ambulatory Surgical Center Quality Reporting (ASCQR) Program	Form and Instruction
Form CMS-10530.ASCQR_Wi CMS-10530.ASCQR_Withdraw Form Ambulatory Surgical Center Quality Reporting (ASCQR) Program	Form and Instruction
Form CMS-10530 Centers for Medicare & Medicaid Services (CMS) Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form Ambulatory Surgical Center Quality Reporting (ASCQR) Program	Form and 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.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 _ECE_Req_Form_CY_2025.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 416

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-10530	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10530.ASCQR_Withdraw Form	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only
Form and Instruction	CMS-10530	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Beneficiary Database

FR Citation: 83 FR 6591

Number of Respondents: 4,590

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

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	18,360	-80,084,140	80,102,500
Annual IC Time Burden (Hours)	40,534	-577,985	618,519
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.

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