CMS-10432 Extroadinary Circumstance/Waiver Request Form

Quality Reporting Program

Extraordinary Circumstance/Disaster Extension or Waiver Request Form
A facility can request an extension or waiver of various Quality Reporting Program requirements due to
extraordinary circumstances beyond the control of the facility. To request an extension or waiver, complete and
submit this form within 30 days of the disaster or extraordinary circumstance.
ALL sections must be complete and specific in order for Centers for Medicare and Medicaid Services to consider
the request.
* Indicates required fields

Facility Contact Information
* Program Requesting Waiver: Inpatient __ Outpatient __ Psych __ Cancer __ ASC __
* Date of Request (MM/DD/YYYY): ____/____/____
* Date of Extraordinary Circumstance/Disaster (MM/DD/YYYY): ____/____/____
* CMS Certification Number (CCN): ____________
* Facility Name: ______________________________________________________________________________
* CEO Last Name: ____________________________________________________________________________
* CEO First Name: ____________________________________________________________________________
* CEO Email Address: _________________________________________________________________________
* CEO Address Line 1: (must include physical street address): _________________________________________
___________________________________________________________________________________________
CEO Address Line 2: _________________________________________________________________________
___________________________________________________________________________________________
* CEO City: ____________________________________________________________________
* CEO State: ____ * CEO Zip Code: _____-_____
* CEO Telephone Number: ___-___-____ ext. __________
Additional Contact Last Name: __________________________________________________________________
Additional Contact First Name: __________________________________________________________________
Additional Contact Email Address: _______________________________________________________________
Additional Contact Address Line 1: (must include physical street address): _______________________________
___________________________________________________________________________________________
Additional Contact Address Line 2: _______________________________________________________________
___________________________________________________________________________________________
Additional Contact City: ________________________________________
Additional Contact State: ____ Additional Contact Zip Code: _____-_____
Additional Contact Telephone Number: ___-___-____ ext. __________

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Quality Reporting Program

Extraordinary Circumstance/Disaster Extension or Waiver Request Form
Disaster Waiver Request Information
* Submission quarter(s) affected (Please state “None” if not applicable): ____________________________
* Validation quarter(s) affected (Please state “None” if not applicable): _____________________________
* Date facility will re-start data submission (MM/DD/YYYY): ____/____/___
* Justification for the submission re-start date: ________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

* Reason(s) for requesting an extension or waiver – Please include the specific requirement or data that
should be waived (attach additional documentation when necessary to include details):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
* Please provide evidence of the impact of the disaster or extraordinary event including (not limited to)
photographs, web links, newspaper and other media articles (attach supporting documentation when
necessary):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Additional Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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Quality Reporting Program

Extraordinary Circumstance/Disaster Extension or Waiver Request Form

Disaster Waiver Request Form Submission
In the event the facility is unable to submit the form electronically, it can be submitted by fax or mailed to your QIO
or CMS designee.

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 0938-1171. 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, Maryland 21244-1850.

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