Form CMS-10621 Hardship Exception Application Form

Centers for Medicare and Medicaid Services
2020 Promoting Operability Hardship Exception Application
Row
1

Field Label
“Add New Exception”

Req’d
Yes

Screen Guidance
Select Exception Type

Data Form
Select One

Possible Values
Exception Type
1. Promoting Interoperability Hardship
Exception
MIPS eligible clinicians, group, and virtual
groups may submit Promoting
Interoperability Hardship Exception
Application citing one of the following
specified reasons:
• You’re a small practice
• You have a decertified EHR
technology
• You have sufficient internet
capability
• You face extreme and
uncontrollable circumstances
such as disaster, practice closure,
severe financial distress, or
vendor issues
• You lack control over the
availability of CEHRT
2. Extreme and Uncontrollable
Circumstances Exception
The Extreme and Uncontrollable
Circumstances application is reserved for
instances where there is indeed an
Extreme and Uncontrollable
Circumstance, such as a natural disaster,
public health emergency or other
significant event, that prevents collecting
data for an extended period of time, or

Row

Field Label

Req’d

Screen Guidance

Data Form

2

“Add New Promoting
Interoperability
Hardship Exception”

Yes

Select Application Type

Select One

3

“Submission
Information”

Yes

Individual Application
Type Details

Select One

4

“Submitter Details”

Yes

Contact Information

Free Text

5

“Submitter Details”

Yes

Contact Information

Select One

6

“Additional Access”

No

Additional Staff Access
Email(s)

Free Text

Possible Values
that could impact performance on cost
measures.
All other events such as vendor issues,
decertification of EHR, etc. should be filed as
a Promoting Interoperability Hardship
Exception.
Application Type
1. Individual
If selected, include Clinician NPI#
2. Group
If selected, include Group TIN#
3. Virtual Group
If selected, include Virtual Group ID#
Group Practice Name
• Select group practice name from drop
down
Contact Information for further information as
needed
1. Phone number
2. Email address
Submitter/Third Party Intermediary Relationship
Select relationship to the party you are
submitting the exception application for
• Other: describe relationship if not listed
Additional Staff Access Email(s)
Enter email address(es) for additional staff you
would like to include for the management of the
form and to receive program announcements.

Row
7

Field Label
“Promoting
Interoperability
Hardship Details”

Req’d
Yes

Screen Guidance
Indicate the Hardship
Exception Reason

Data Form
Select one

8

“Insufficient Internet
Connectivity Details”

Yes, if this
reason
was
selected

Attest to insufficient
internet connectivity

Select One

9

“Extreme and
Uncontrollable
Circumstance Details”

Yes, if this
reason
was
selected

Indicate the type of
Extreme and
Uncontrollable
Circumstance

Select One

Possible Values
Reason for Promoting Interoperability Hardship
1. Insufficient Internet Connectivity
2. Extreme and Uncontrollable
Circumstance
3. Lack of Control over the Availability of
CEHRT
4. EHR Decertification
5. Small Practice
In order to be approved for this hardship
exception, the clinician(s) must attest to
practicing in an area without sufficient internet
access or facing insurmountable barriers to
obtaining infrastructure (e.g. lack of broadband).
• Attest to insufficient internet connectivity
• Event description (optional)
Extreme and Uncontrollable Circumstance Event
Type:
1. Event Type
• Disaster
• Practice or Hospital Closure
• Severe Financial Distress
(bankruptcy or debt
restructuring)
• Vendor Issue
2. Event Date Range
• Indicate the start and end dates
for the period of time for which
the clinician(s) were unable to
collect or submit data.
3. EHR Certification ID if applicable
4. Attest to extreme and uncontrollable
circumstance
5. Event description (optional)

Row
10

Field Label
“Lack of Control over
the Availability of
CEHRT”

Req’d
Yes, if this
reason
was
selected

Screen Guidance
Attest to lack of control
over the availability of
CEHRT

Data Form
Select One

11

“EHR Decertification”

Yes, if this
reason
was
selected

Attest to EHR
decertification

Select One

Possible Values
In order to be approved for this hardship
exception, the clinician(s) must attest to lack of
control over the availability of CEHRT in 1 or
more practice locations where more than 50
percent of the patient encounters occurred.
• Attest to lack of control over the
availability of CEHRT
• Event description (optional)
In order to be approved for this hardship
exception, the clinician(s) must attest to
experiencing issues with the certification of the
EHR product such as certification.
• Event Start Date
o Indicate the date of EHR
decertification
• Provide ONC-ACB Certification ID
• Attest to EHR decertification
• Event description (Optional)

Row
12

Field Label
“Submit for Review”

Req’d
Yes

Screen Guidance
Certify and Submit for
Review

Data Form
Select One

Possible Values
Review Submission Summary and Certification
Information, Certify & Submit
1. Review submission information selected
or included
• Individual, Group, or Virtual
Group application details
• Submitter details
• Additional Access
2. Review Promoting Interoperability Details
• Reason for Promoting
Interoperability Hardship
• Event Description
3. Review General Application Notice
• Disclosures, notices and
certification of the clinician(s) or
submitter working on behalf of
the clinician(s)
• By submitting this Promoting
Interoperability Exception
Application, I am certifying that
the details entered are correct to
the best of my knowledge.
Furthermore, I am submitting this
request as if a physically signed
and submitted a hard copy of this
form.

Row
13

Field Label
“Application for
NPI/TIN is approved”

Req’d
N/A

Screen Guidance
The PI Hardship
application for NPI/TIN is
approved.

Data Form
N/A

Possible Values
Automatic notification indicating application is
approved for the identified NPI/TIN with a note.
If the clinician associated with this application
reports any data as an individual for the
Promoting Interoperability (PI) performance
category, the clinician will be scored for the
Promoting Interoperability category and this
application will be dismissed.