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Public Reporting Extension Request Form

Month DD, YYYY
Point of Contact and Executive
Entity
Address
City, State ZIP Code
Director, Office of Enterprise Data & Analytics
Centers for Medicare & Medicaid Services (CMS)
7500 Security Boulevard
Mail stop: B2-29-04
Baltimore, Maryland 21244-1850
Dear Director:
This letter is to request an extension for the release of our public performance reports as a certified
Qualified Entity (QE). While we have been diligently working to publicly report within [one year of
receipt of the QE Medicare data with a public reporting deadline of Month DD, YYYY, OR our public
report date of Month DD, YYYY], we discovered that we are unable to meet this goal. This is QE Name’s
first, second, third, etc. request for an extension. QE Name’s previous extension request was approved
by CMS, and CMS extended our public reporting deadline by XX months [If QE has previously received an
extension: [QE’s Name]’s previous extension request was approved by CMS and extended our public
reporting deadline by [XX] months.].
We attest that [QE Name] has not used the QE Medicare data for any additional permissible uses,
including non-public analyses and dissemination of combined or Medicare-only data.
We re-evaluated our program progress at this time and present an updated timeline for the release of
our public report by Month DD, YYYY. in Attachment A. In Attachment B, we provide our rationale for
requiring a public reporting extension, an explanation of how QE Name has used the QE Medicare Data
since it was received on Month DD, YYYY, and whether we have engaged in additional permissible uses.
In Attachment A, we provide our rationale for requiring a public reporting extension, an explanation of
how [QE Name] has used the QE Medicare data since it was received on [MM/DD/YYYY]. Following the
review of our updated timeline, we request that CMS grant [QE Name]an extension for the date by
which we must release our QE public performance report.
By signing this document, we attest that we cannot engage in additional permissible uses until we have
published and received notice of meeting requirements for our public report.
Sincerely,
Name of Applicant Entity
___________________________________

______________

Signature of Authorized Officer

Date

1

Attachment A: Phase 3 Elements Report
___________________________________
Name and Title of Authorized Officer
Table 1: Authorized Officer Signature
Name
Title
Authorized Officer Name

Authorized Officer Title

Signature

Date

Authorized Officer Signature

MM/DD/YYYY

Attachment A

Milestone

QE Updated Request
Date

Phase 3 Evidence Submitted (Elements 3.1 to 3.3)

MM/DD/YYYY

Initiation of Provider Corrections and Appeals Process (required 60 days before the
Public Report)

MM/DD/YYYY

Public Report Released

MM/DD/YYYY

A-1

Attachment A B
1. Rationale as to why a public reporting extension request letter is needed:
Entity to Complete Entity to insert rationale

2. Explanation of how the QE Medicare data has been used by [QE Name] QE since it was received
on [MM/DD/YYYY]Month DD, YYYY:
Entity to Complete Entity to insert explanation

3. Has the QE engaged in any additional permissible uses with Authorized users since receiving the
CMS data? If yes, please explain.
Entity to insert response/explanation

A-2