CMS-10210 Extraordinary Circumstances Form

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
A hospital or healthcare facility that has experienced an extraordinary circumstance(s) that affected the
ability of the healthcare facility to comply with one or more applicable quality reporting and value-based
purchasing program reporting requirements may submit this form to CMS within 30 calendar days of the
date the extraordinary circumstance occurred (or by April 1st or June 15th following the end of the
reporting year in which the extraordinary circumstance occurred for electronic clinical quality measures
(eCQMs) for the Hospital Inpatient Quality Reporting Program and Hospital Outpatient Quality Reporting
Program, respectively) to request an exception or extension for the requirement(s). An extraordinary
circumstance is an event beyond the control of a healthcare facility (for example, a natural or man-made
disaster such as a hurricane, tornado, earthquake, terrorist attack, or bombing, or issues with CMSdesignated information systems that directly affect the ability of the facility to submit data).
CMS may grant either an exception or, if appropriate under the circumstances, an extension of time to
comply with one or more reporting requirements indicated. Please refer to the Federal Register and Code
of Federal Regulations for additional information regarding program-specific ECE policies.
Note: An ECE request form may be submitted for multiple programs, requirements, and/or reporting
periods. CMS reviews ECE requests on a case-by-case basis. The submission of an ECE request
does not guarantee complete or partial approval.
An asterisk (*) indicates required fields. All sections must be complete and specific for CMS to
consider the request.
____________________________________________________________________________________
Facility Contact Information
*Facility Name
*CMS Certification Number (CCN)
*National Provider Identifier Number (NPI) (ASC only)
(Place additional NPIs in Additional Comments section.)
*CEO/Designee Contact Information
*Name ______________________________________ *Title _______________________________
*Address (must include physical street address) __________________________________________
*City ____________________________________ *State _________________ *Zip Code ________
*Telephone Number _____________________________ *Extension _________________________
*Email Address ___________________________________________________________________
Additional Contact Information
Name _________________________________________ Title _________________________________
Address (must include physical street address)_______________________________________________
City_______________________________________ State _____ ZIP Code_______________________
Telephone Number________________________ Extension____________________________________
Email Address_________________________________________________________________________
*Dates
*Date of Request
January 2026

*Date of Extraordinary Circumstance ______________________
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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
*Program(s) and Program Requirement(s) for Which Facility is Requesting an ECE
Please indicate which program requirement(s) and reporting period(s) for each requirement which you are
requesting exception or extension for an extraordinary circumstance.
Program
Ambulatory
Surgical
Center Quality
Reporting
(ASCQR)
Program

Measure and/or Program Requirement

Reporting
Periods

☐ National Healthcare Safety Network (NHSN) Measures
☐ Web-based Measure(s)

☐ Patient-Reported Outcome-Based Performance Measure(s) (PRO-PMs)

☐ Outpatient and Ambulatory Surgical Consumer Assessment of Healthcare Providers
and Systems (OAS CAHPS)
☐ Other (Please specify):

_______________________________________________________________________
End-Stage
Renal
Disease
Quality
Incentive
Program
(ESRD QIP)

☐ In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems
(ICH CAHPS) Survey
☐ National Healthcare Safety Network (NHSN)
☐ ESRD Quality Reporting System (EQRS)
☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
HospitalAcquired
Condition
(HAC)
Reduction
Program

☐ National Healthcare Safety Network (NHSN) Measures

Hospital
Inpatient
Quality
Reporting
(IQR)
Program

☐ Chart-abstracted Measure(s)

☐ Validation
☐ Other (Please specify):

_______________________________________________________________________
☐ Electronic Clinical Quality Measures (eCQMs)
☐ Hybrid Measure(s)

☐ Patient-Reported Outcome-Based Performance Measure(s)

☐ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey
National Healthcare Safety Network (NHSN) Measures
☐ Influenza Vaccination Coverage Among Healthcare Personnel

☐ Patient Safety Structural Measure

☐ CAUTI-Onc

☐ CLABSI-Onc

January 2026

☐ Web-based Structural Measure(s)

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Program

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Measure and/or Program Requirement

Reporting
Periods

☐ Population and Sampling

☐ Chart-abstracted Validation
☐ eCQM Validation

☐ Other (Please specify):

_______________________________________________________________________
Hospital
Outpatient
Quality
Reporting
(OQR)
Program

☐ Chart-abstracted Measure(s)
☐ Web-based Measure(s)

☐ National Healthcare Safety Network (NHSN) Measures
☐ Electronic Clinical Quality Measures (eCQMs)

☐ Patient-Reported Outcome-Based Performance Measure(s)

☐ Outpatient and Ambulatory Surgical Consumer Assessment of Healthcare Providers
and Systems (OAS CAHPS)
☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
Hospital
Readmissions
Reduction
Program
(HRRP)

☐ Other (Please specify):

Hospital
Value-Based
Purchasing
(VBP)
Program

☐ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey

_______________________________________________________________________

☐ NHSN Healthcare-associated infection (HAI) Measure(s)

☐ Severe Sepsis and Septic Shock Management Bundle (Composite Measure)
☐ Other (Please specify):
_______________________________________________________________________

Inpatient
Psychiatric
Facility
Quality
Reporting
(IPFQR)
Program

☐ Chart-abstracted Measure(s)
☐ Web-based Measure(s)

☐ National Healthcare Safety Network (NHSN) Measure(s)
☐ Chart-abstracted Measure(s)
☐ Other (Please specify):

_______________________________________________________________________
Rural
Emergency
Hospital
Quality
Reporting
(REHQR)
January 2026

☐ Chart-abstracted Measure(s)
☐ Web-based Measure(s)
☐ Other (Please specify):

_______________________________________________________________________
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Program

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Measure and/or Program Requirement

Reporting
Periods

Program
PPS-Exempt
Cancer
Hospital
Quality
Reporting
(PCHQR)
Program

☐ Web-based Measure(s)

☐ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey
☐ National Healthcare Safety Network (NHSN) Measure(s)
☐ Other (Please specify):

_______________________________________________________________________

ECE Request Information
*Date ECE relief would end
*Provide justification for the ECE end date and provide details if there are any reason(s) your healthcare
facility may not be able to fully complete reporting requirements if an extension (versus an exception) is
granted.

January 2026

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
*Enter the specific requirement(s) or data for which you are seeking an ECE. Provide details as to how
the extraordinary circumstance prevented your healthcare facility from complying with the reporting
requirement(s) for the program(s) and/or requirement(s) for which this ECE is being sought.

*Provide supporting evidence of the impact of the extraordinary circumstance including (but not
limited to) photographs, web links, newspaper, and other media articles. Attach supporting
documentation as applicable.

January 2026

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Provide any additional information you would like CMS to consider when assessing and determining
your ECE request.

*CEO/Designee Signature:

*Date:

Extraordinary Circumstances Exception Request Form Submission Instructions
Complete and submit this form, via the Hospital Quality Reporting Secure Portal, Managed File Transfer to
QRFormsSubmission@hsag.com. You may instead submit via email to QRFormsSubmission@hsag.com or
secure fax to (877) 789-4443.
For ESRD QIP only, please complete and submit this form to the ESRD QIP mailbox at esrdqpsadmin@arborresearch.org.
Following receipt of the request form, CMS will (1) Provide a written acknowledgement using the contact
information provided in the request, to the CEO and any additional designated facility personnel, notifying
them that the facility’s request has been received and (2) provide a formal response to the CEO and any
additional designated facility personnel using the contact information provided in the request notifying them of
our decision. CMS will strive to complete its review of each ECE request within 90 calendar days of receipt of
the request.
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 0938-1022 (Expires XX-XX-20XX). The time required to complete this information
collection is estimated to average 15 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, MD 21244-1850.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records, or any documents containing sensitive information
to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under
the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support
Contractor at (844) 472-4477.

January 2026

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