CMS-10530 Extroadinary Circumstance Online Form

Quality Reporting Program

Extraordinary Circumstances/Disaster Extension or Exemption Request Form

A facility can request an extension or exemption of various Quality Reporting Program requirements due to extraordinary circumstances beyond the control of the facility. To request an extension or exemption, complete and submit this form within 30 days of the disaster or extraordinary circumstance.

ALL sections must be complete and specific in order for the Centers for Medicare and Medicaid Services to consider the request.

*Indicates required fields

Facility Contact Information

_{*Program Requesting Extension or Exemption:}

Inpatient

_Outpatient

Inpatient Psych

_{PPS-Exempt Cancer}

ASC

*Date of Request *Date of Extraordinary Circumstance/Disaster

*Facility Name

* Place additional NPIs in Additional Comments section.

*CMS Certification Number (CCN)

or NPI (10 digits)

_{CEO Contact Information}

_{*Last Name *First Name}

_{*Address (must include physical street address)}

_*City *State _{*ZIP Code}

*Telephone Number Ext. *E-Mail Address

_{Additional Contact Information}

_{Last Name First Name}

_{Address (must include physical street address)}

_City State _{ZIP Code}

Telephone Number Ext. E-Mail Address

_{Disaster Extension or Exemption 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}

*Justification for the submission re-start date:

* Reason(s) for requesting an extension or exemption - Please include the specific requirement or data that should be extended or exempted. (Attach additional documentation when necessary to include details.)

* Please provide evidence of the impact of the disaster or extraordinary event including (but not limited to) photographs, Web links, newspaper and other media articles. Attach supporting documentation when necessary.

* Additional comments:

Disaster Extension or Exemption Request Form Submission

In the event the facility is unable to submit the form electronically, it can be submitted by fax or mailed to their 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 XXXX-XXXX. 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 21244-1650.