CMS-10431 Extroadinary Circumstances/Disaster Extension or Waiver

Quality Reporting Program
Extraordinary Circumstance/Disaster Extension or Waiver Request Form
A facility can request an extension or waiver of various Quality Reporting Program requirements due to extraordinary
circumstances beyond the control of the facility. To request an extension or waiver, complete and submit this form

within 30 days of the disaster or extraordinary circumstance.

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

Facility Contact Information
*Program Requesting Waiver:

O Inpatient

O

O Outpatient

*Date of Request

I

Inpatient Psych

O PPS-Exempt

Cancer

*Date of Extraordinary Circumstance/Disaster

*CMS Certification Number (CCN)

*Facility Name

I

CEO Contact Information
*Last Name

*First Name

*Address (must include physical street address)
*State

*City
*Telephone Number

Ext.

*ZIP Code
*E-Mail Address

Additional Contact Information
Last Name

First Name

Address (must include physical street address)
City

State

Telephone Number

Ext.

ZIP Code
E-Mail Address

Disaster Waiver 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:

O ASC

*Reason(s) for requesting an extension or waiver - Please include the specific requirement or data that should
be waived. (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 Waiver 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.

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