CMS-10431 Extroadinary Circumstance Paper Form

Quality Reporting Program
Extraordinary Circumstance/Disaster Extension or Waiver Request Form (Paper
Submission)
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

O PPS-Exempt

Inpatient Psych

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.

Complete and submit the Notice of Participation Agreement form using one of the following options:
•
via My QualityNet to the Global Exchange Group “PPS Exempt Cancer Hosp. QR Support ”;
•
via secure FAX to Program Manager Telligen PCHQR Support (515)-558-5073, or
•
via mail to:
Telligen PCHQR Support
1776 West Lakes Parkway,
West Des Moines, IA 50266
Attn. Program Manager
DO NOT SEND THE COMPLETED FORM VIA E-MAIL.
Following receipt of the request form, an e-mail acknowledgement will be sent confirming the form has been received.
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.