CMS-10250 Extroadinary Circumstances

Hospital OQR Extraordinary Circumstances
Extension or Waiver for Reporting Quality Data*

Date of Request
Date of Extraordinary Circumstance
Hospital ID/CCN
Hospital Name
Contact Information for Hospital
CEO or Other Hospital-Designated
Personnel
E-Mail Address of Hospital CEO or
other Hospital-Designated
Personnel
Telephone Number of Hospital CEO
or Other Hospital-Designated
Personnel
Address (no post office boxes,
please) of Hospital CEO or Other
Hospital-Designated Personnel
City
State and ZIP Code
Name of Additional Designated
Personnel
Designated Personnel E-Mail
Address
Designated Personnel Address (no
post office boxes, please)
City
State and ZIP Code
Type of Extraordinary Circumstance

Hospital’s Reason for Requesting
an Extension or Waiver

Revised 11.14.12

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Evidence of the Impact of the
Extraordinary Circumstance, e.g.,
Photographs, Newspaper and Other
Media Articles, etc.

Submission Quarters Affected

Validation Quarters Affected
Estimated Date When Hospital
Would Again Be Able to Submit
Hospital OQR Data
Justification for Proposed Date

Additional Comments

*Please attach additional pages or documents as necessary.

Signature, Chief Executive Officer
or Other Hospital-Designated Personnel

(Print Name)

This material was prepared by FMQAI, the Support Center for the Hospital Outpatient Quality Reporting program, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). The contents
presented do not necessarily reflect CMS policy. FL-10SOW-2013FS4T11-1-522

Revised 11.14.12

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