CMS-10210 Extraordinary Circumstances Form

Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program
Extraordinary Circumstances Extensions/Exemptions Request Form
A facility can request an extension of or exemption from various Quality Reporting requirements due to
extraordinary circumstances beyond the control of the facility. To request an extension or exemption, complete
and submit this form. Hospital Inpatient, Inpatient Psychiatric, and PPS-Exempt Cancer Hospitals must be
submitted within 30 days of the extraordinary circumstance. Hospital Value-Based Purchasing, HospitalAcquired Condition Reduction, and Hospital Readmissions Reduction must be submitted within 90 days of
the extraordinary circumstance. Ambulatory Surgical Center and Hospital Outpatient must be submitted
within 45 days of the extraordinary circumstance.
All sections must be complete and specific in order for the CMS to consider the request.

*Indicates required fields
*Facility Contact Information
*Program Requesting Extension/Exemption
Hospital
Inpatient

Inpatient
Psychiatric

PPS-Exempt
Cancer Hospitals

Hospital-Acquired
Condition Reduction

Hospital Readmissions
Reduction

Hospital
Outpatient

*Date of Request

Hospital
Value-Based
Purchasing
Ambulatory
Surgical Centers

*Date of Extraordinary Circumstance

*Facility Name
*CMS Certification Number (CCN)
(Place additional NPIs in
Additional Comments
section.)

*National Provider Identifier Number (NPI) (ASC only)
CEO/Designee Contact Information
*First Name

*Last Name
*Address (must include physical street address)
*City

*State

*Telephone Number

Ext.

‘
*ZIP Code
*E-Mail Address

Additional Contact Information
First Name

Last Name
Address (must include physical street address)
City

State

Telephone Number

Ext.

‘'
ZIP Code
E-Mail Address

Extraordinary Circumstances Extension/Exemption Request Form
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 restart data submission
*Provide justification for the submission restart date.

*Enter reason for requesting an extension or exemption. Please include the specific requirements or
data that should be extended or exempted. Attach supporting documentation when necessary.

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

Additional Comments (Attach additional documentation/comments if necessary):

*Signature:

*Date:

Extraordinary Circumstances Extension/Exemption Request Form Submission Instructions
Complete and submit this form via the QualityNet Secure Portal, Secure File Transfer “WAIVER EXCEPTION
WITHHOLDING” group. If unable to submit via Secure File Transfer, please submit via e-mail to
[email protected], secure fax to 877-789-4443, or mail to 3000 Bayport Drive, Suite 300, Tampa, FL
33607. The Support Contractor will forward, as directed, to CMS.
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 0938-1022.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 estimates(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, MD 21244-1650.

Updated March 2015

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