Notification of Extraordinary Circumstances Extension or Waiver Form

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

In the event that an Ambulatory Surgical Center (ASC) is unable to submit any required information (e.g., medical records, data) due to an extraordinary circumstance, such as a natural disaster, the ASC may request an extension or waiver. The ASC will need to complete the Extraordinary Circumstances Extension or Waiver form (PDF-103 KB) and submit the form with any required information and supporting documentation within 45 calendar days of the date of the extraordinary circumstance. These documents must be submitted to the Ambulatory Surgical Center Support Contractor via fax (877-789-4443) or by conventional mail to:

FMQAI
ATTN: Ambulatory Surgical Center Quality Reporting Program
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609

Ambulatory Surgical Centers that are included under a blanket waiver by CMS (due to widespread natural disasters such as hurricanes, tornadoes, etc.) will not be required to submit the Extraordinary Circumstances Extension or Waiver form.

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