Form CMS-10210 Data Accuracy and Completeness Form

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.
To the best of my knowledge, at the time of submission, all the information reported for this
hospital to the Centers for Medicare & Medicaid Services (CMS) is accurate and complete. This
information includes the following:
• Quality measure data (including, but not limited to Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) Survey data, data from the electronic
health record (EHR) used in eCQMs and hybrid measures, National Healthcare Safety
Network data)
• Claims data
• Initial patient population and sample counts
• Notice of Participation
To the best of my knowledge, at the time of submission, 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 and patient assessment of care data, for annual
payment updates under the Hospital Inpatient Quality Reporting Program, and for value-based
payment adjustments under the Hospital-Acquired Condition Reduction Program, the Hospital
Readmissions Reduction Program, and the Hospital Value-Based Purchasing Program.
I understand this acknowledgement covers all inpatient hospital information reported by this
hospital (and any data or survey information reported by any vendors acting as agents on behalf
of this hospital) to CMS and its contractors.

[ ] Yes, I Acknowledge.
Name __________________________________________
Position ________________________________________
Date ___________________________________________

January 2026