Retired Measure Substitution Form


  • Form is also available in Portable Document Format (PDF)

VBP QIP Facilities should use this form to notify DOH that a selected quality performance measure has been retired and to indicate what measure is being substituted. Substitute measures should come from the same measure category.

Facility Name:
Alternate Measure Name Retired:
Alternate Measure Name Replacement:
  1. Provide link to measure specifications:
  2. Measure derived from the following population:
    • All Payer data
    • Medicare data
    • Medicaid data
  3. Organization providing baseline:
  4. Baseline data collected for the time period:
  5. Baseline is based on the following sample:
    • National
    • State
    • Other, specify:__________________________________
  6. Baseline is derived from the following population:
    • All Payer
    • Medicare
    • Medicaid
  7. Baseline value is:
      Mean         Median
  8. Baseline value is Un-Weighted:
      Yes           No

Please email your reply to To discuss the results in further detail, please contact us at Thank you for your participation in this program.