Crosswalk

Form	Notes on Updates
Notice of Participation	No updates/changes to previously submitted form; Form still in use
Data Accuracy and Completeness Acknowledgement	No updates/changes to previously submitted form; Form still in use
Request for Withholding Data from Public Reporting	No updates/changes to previously submitted form; Form still in use
Measure Exception Form	Form resubmitted with updates to allow for exceptions to reporting Perinatal Care (PC) and Emergency Department (ED) measures, in addition to Healthcare-Associated Infection (HAI) measures and to add Hospital Value-Based Purchasing and Hospital-Acquired Condition (HAC) Reduction Programs
Reconsideration Request Form	No updates/changes to previously submitted form; Form still in use
HVBP Review and Corrections Form	No updates/changes to previously submitted form; Form still in use
HVBP Appeals Form	No updates/changes to previously submitted form; Form still in use
Extraordinary Circumstances Extensions/Exemptions Request Form	No updates/changes to previously submitted form; Form still in use
Validation Review for Reconsideration Request	No updates/changes to previously submitted form; Form still in use
Validation Template for Central Line Associated Bloodstream Infection (CLABSI)	No updates/changes to previously submitted form; Form still in use
Validation Template for Catheter-Associated Urinary Tract Infection (CAUTI)	No updates/changes to previously submitted form; Form still in use
Validation Template for MRSA Bacteremia (MRSA)	No updates/changes to previously submitted form; Form still in use
Validation Template for Clostridium Difficile (CDI)	No updates/changes to previously submitted form; Form still in use

Summary of HIQR Information Collection Forms: Updates for the FY 2016 IPPS Proposed Rule

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