cms-10552 Medicare Promoting Interoperability Program Hardship Exc

CMS.gov
Medicare Promoting Interoperability Program Hardship Exception Application
Eligible hospitals and Critical Access Hospitals (CAH) may submit a Medicare Promoting Interoperability (Pl) Exception Application citing one of the following specified reasons for review and
approval:
• Using decertified EHRtechnology
• Insufficient Internet Connectivity
• Extreme and Uncontrollable Circumstances

0

Important dates and information

If you are an eligible hospital, you must submit an application by September 02, 2025 for CMSto process your hardship exception request for the 2026 payment adjustment. The
application will be available from May 1, 2025 - September 02, 2025.
If you are a CAH, you must submit an application by October 31, 2025 for CMSto process your hardship exception request the 2024 payment adjustment. The application will be
available from May 1, 2025 - October 31, 2025.
For additional support or if you have any questions, please contact the CCSQService Center at qnetsupport@cms.hhs.gov, call 866-288-8912 or CCSQSupport Central.

* Indicates required
*which form would you like to complete today?

&

MedicarePl ProgramEligible HospitalHardship
* Hospital CCN (6 Numeric digits only, example: 123456)

8

010001

Hospital Legal name

I

8

HOUSTONCOUNTYHEALTHCARE
AUTHORITY

ApplicantInformation
Provide the information below for the person working on behalf of the Hospital or CAH.All return correspondence will be sent to the contact listed in section Applicant Information.

* Submitter first name
Em
* Submitter last name
Smith
* Hospital or Organization name

&

[ Hope Hospital
* Submitter email

I

em@gmail.com

* Confirm submitter email

I

em@gmail.com

* Submitter telephone number
7035551212
Extension

xxxxxxx
* Address
123 Elm St

Suite/ apartment/

unit number

*City
Houston

State
Texas
*zip Code

0
■

&

77001

"

*I certify that I am authorized by the hospital identified

above to submit this application on behalf of the hospital.

Request for promoting interoperability program hardship exception
Reviewthe information below and indicate one hardship exception reason which makes the Medicare Promoting Interoperability Program measures not applicable or available to your
practice.
Note: Only one hardship exception reason can be selected at this time.

* Hardship exception reason

8

( Insufficient Internet Connectivity

In order to be approved for this hardship exception, the Hospital or CAHmust attest to practicing in an area without sufficient internet accessor facing insurmountable barriers to obtaining
infrastructure (e.g. lack of broadband).
On behalf of the Hospital or CAHlisted in this application, I am requesting this hardship exception and attest that the Hospital or CAHwas(were) located in an area without sufficient Internet accessto
comply with the Medicare Promoting Interoperability Program objectives requiring internet connectivity, and faced insurmountable barriers to obtaining such internet connectivity. I further attest
that this insufficient internet connectivity constitutes a significant hardship in demonstrating meaningful use as defined under: 42 CFR412.64(d)(4)(ii)(A).

Certificationstatement for hardshipapplication
NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete, or misleading information may be guilty of a criminal act
punishable under law and may be subject to civil penalties.

SIGNATUREOF HOSPITALREPRESENTATIVE
I certify that the information contained herein is true, accurate, and complete. I understand that the Medicare Promoting Interoperability Program Hardship Exception I requested may result
in a change in the amount the Hospital will be paid from Federal funds, and that by filling this application for a hardship exception I am submitting a claim for Federal funds, and the use of
any false claims, statements, or documents, or the concealment of a material fact used to obtain a Medicare Promoting Interoperability Program Hardship Exception, may be prosecuted
under applicable Federal or st.ate criminal laws and may also be subject to civil penalties.
SUBMITTER WORKING ON BEHALF OF HOSPITAL(s): I certify that I am submitting this application for a payment adjustment on behalf of the hospital(s) that has (have) given me authority
to act as agent. I understand that both the hospital(s) and I can be held personally responsible for all information entered.
I hereby agree to keep such records as are necessary to support the application submitted for a hardship exception of the Medicare Promoting Interoperability Program and to furnish those
records both in the application and at a future time upon request from the Department of Health and Human Services, or a contractor acting on their behalf.
No Medicare Promoting Interoperability Program hardship exception may be granted unless this application is completed and approved as required by existing law and regulations (42 CFR
§412.64(d)I 4 )Iii) I.
NOTICE:Anyone who misrepresents or falsifies essential information to receive payment from Federal funds requested by this application may upon conviction be subject to fine and
imprisonment under applicable Federal laws.
ROUTINE USE(S): Information from this Medicare Promoting Interoperability Program application for hardship exception and subsequently submitted information and documents may be
given to the Internal Revenue Service, private collection agencies, consumer reporting agencies in connection with recoupment of any overpayment made and to Congressional offices in
response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other Federal, state, local and foreign government agencies,
private business entities and individual providers of care, on matters relating to entitlement, fraud, Program abuse, Program integrity, and civil and criminal litigation in relation to the
operation of the Medicare Promoting Interoperability Program.
DISCLOSURES:While submission of information for this hardship exception application is voluntary, failure to provide necessary information for hospital identification will result in delay in
processing the hardship exception application or may result in a denial.
It is mandatory that you tell us if you believe you have been overpaid under the Medicare Promoting Interoperability Program. The Social Security Act, Section 1128J, requires the reporting
and returning of overpayments.
By confirming this certification statement, I agree, and it is my intent, to sign this application and affirmation by including my name and the date below. I understand that completing the
information below is the legal equivalent of having placed my handwritten signature on the submitted application and this affirmation.

D • Certify statement for hardship
* Name of individual completing the form

D

I'm not a robot
reCAPTCHA
Prllf!!cy -Terms

Submit

Required information
Certify statement for hardship

Name of individual completing the form

WARNING:Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the Privacy Act of 1974. Submission
to the Hospital Hardship that contains Protected Health Information (PHI) and Personally Identifiable Information (PII) is a violation of these Acts. Questions containing PHI will be deleted
from the system and not processed. For detailed information regarding safeguarding protected healthcare information or data, please refer to the CMSQualityNet System Privacy Policy.

INFORMATIONNOT TO BE RELEASEDTO PUBLICUNLESSAUTHORIZEDBY LAW:This information is for internal Government use only and has not been publicly disclosed. It may contain
information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share Personally Identifiable Information (PII) and/or Protected Health
Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of the law.

A federal government website managed
Medicare Promoting Interoperability Program Hardship

and paid for by the U.S. Centers for

Exception Application

Medicare & Medicaid Services. 7500
Security Boulevard, Baltimore MD 21244

CMS.gov
Medicare Promoting Interoperability Program Hardship Exception Application
Eligible hospitals and Critical Access Hospitals (CAH) may submit a Medicare Promoting Interoperability (Pl) Exception Application citing one of the following specified reasons for review and
approval:
• Using decertified EHRtechnology
• Insufficient Internet Connectivity
• Extreme and Uncontrollable Circumstances

0

Important dates and information

If you are an eligible hospital, you must submit an application by September 02, 2025 for CMSto process your hardship exception request for the 2026 payment adjustment. The
application will be available from May 1, 2025 - September 02, 2025.
If you are a CAH, you must submit an application by October 31, 2025 for CMSto process your hardship exception request the 2024 payment adjustment. The application will be
available from May 1, 2025 - October 31, 2025.
For additional support or if you have any questions, please contact the CCSQService Center at qnetsupport@cms.hhs.gov, call 866-288-8912 or CCSQSupport Central.

* Indicates required
*Which form would you like to complete today?

8

MedicarePl ProgramEligibleHospitalHardship
* Hospital CCN(6 Numeric digits only, example: 123456)

G

010001
Hospital Legal name

I

0

HOUSTONCOUNTYHEALTHCARE
AUTHORITY

ApplicantInformation
Provide the information below for the person working on behalf of the Hospital or CAH.All return correspondencewill be sent to the contact listed in section Applicant Information.

* Submitter first name

Em
* Submitter last name
Smith
* Hospital or Organization name

G

[ Hope Hospital
* Submitter email
[ em@gmail.com
* Confirm submitter email
[ em@gmail.com
* Submitter telephone number
7035551212
Extension
JO()()()()()(

* Address
123 Elm St
Suite/ apartment/ unit number

*city
Houston
State
Texas

0

*zipCode

0
■

..

77001

* I certify that I am authorized by the hospital identified

above to submit this application on behalf of the hospital.

Requestfor promotinginteroperabilityprogramhardshipexception
Reviewthe information below and indicate one hardship exception reason which makesthe Medicare Promoting Interoperability Program measuresnot applicable or available to your
practice.
Note: Only one hardship exception reason can be selected at this time.

• Hardship exception reason

G

..

Extremeand UncontrollableCircumstances
• Extreme and Uncontrollable Circumstances

0

Disaster
On behalf of the Hospital or CAH listed in this application, I am requesting this hardship exception and attest that the Hospital or CAHfaced Extreme and Uncontrollable
Circumstances in the form of a natural disaster in which the EHRsystem was damaged or destroyed, or the Hospital or CAHfaced Extreme and Uncontrollable Circumstances in the
form of a Health Pandemic. I further attest that this Extreme and Uncontrollable Circumstance in the constitutes a significant hardship in demonstrating meaningful use as defined
under: 42 CFR412.64 (d)(4)(ii)(B).
Period of time the EHRsystem was unavailable (MM/DD/YYYY)
to (MM/DD/YYYY).
• Start date

-

1111

• End date

-

1111

Certification statement for hardship application
NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete, or misleading information may be guilty of a criminal act
punishable under law and may be subject to civil penalties.
SIGNATUREOF HOSPITAL REPRESENTATIVE
I certify that the information contained herein is true, accurate, and complete. I understand that the Medicare Promoting Interoperability Program Hardship Exception I requested may result
in a change in the amount the Hospital will be paid from Federal funds, and that by filling this application for a hardship exception I am submitting a claim for Federal funds, and the use of
any false claims, statements, or documents, or the concealment of a material fact used to obtain a Medicare Promoting Interoperability Program Hardship Exception, may be prosecuted
under applicable Federal or state criminal laws and may also be subject to civil penalties.
SUBMITTERWORKING ON BEHALFOF HOSPITAL(s}: I certify that I am submitting this application for a payment adjustment on behalf of the hospital(s) that has (have) given me authority
to act as agent. I understand that both the hospital(s) and I can be held personally responsible for all information entered.
I hereby agree to keep such records as are necessary to support the application submitted for a hardship exception of the Medicare Promoting Interoperability Program and to furnish those
records both in the application and at a future time upon request from the Department of Health and Human Services, or a contractor acting on their behalf.
No Medicare Promoting Interoperability Program hardship exception may be granted unless this application is completed and approved as required by existing law and regulations (42 CFR
§412.64Idi( 4)Iii)).
NOTICE:Anyone who misrepresents or falsifies essential information to receive payment from Federal funds requested by this application may upon conviction be subject to fine and
imprisonment under applicable Federal laws.
ROUTINE USE(S): Information from this Medicare Promoting Interoperability Program application for hardship exception and subsequently submitted information and documents may be
given to the Internal Revenue Service, private collection agencies, consumer reporting agencies in connection with recoupment of any overpayment made and to Congressional offices in
response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other Federal, state, local and foreign government agencies,
private business entities and individual providers of care, on matters relating to entitlement, fraud, Program abuse, Program integrity, and civil and criminal litigation in relation to the
operation of the Medicare Promoting Interoperability Program.
DISCLOSURES:While submission of information for this hardship exception application is voluntary, failure to provide necessary information for hospita I identification will result in delay in
processing the hardship exception application or may result in a denial.
It is mandatory that you tell us if you believe you have been overpaid under the Medicare Promoting Interoperability Program. The Social Security Act, Section 1128J, requires the reporting
and returning of overpayments.
By confirming this certification statement, I agree, and it is my intent, to sign this application and affirmation by including my name and the date below. I understand that completing the
information below is the legal equivalent of having placed my handwritten signature on the submitted application and this affirmation.

D

*certify statement for hardship

• Name of individual completing the form

D

I'm not a robot
reCAPTCHA
Privacy -Terms

Submit

Required information
Start date

l#t@i

WARNING:Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the Privacy Act of 1974.
Submission to the Hospital Hardship that contains Protected Health Information (PHI) and Personally Identifiable Information (PII) is a violation of these Acts. Questions containing PHI
will be deleted from the system and not processed. For detailed information regarding safeguarding protected healthcare information or data, please refer to the CMSQualityNet System
Privacy Policy.

INFORMATIONNOT TO BE RELEASED
TO PUBLIC UNLESSAUTHORIZEDBYLAW:This information is for internal Government use only and has not been publicly disclosed. It may contain
information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share Personally Identifiable Information (PII) and/or Protected Health
Information (PHI), Unauthorized disclosure may result in prosecution to the full extent of the law.

CMS.gov
Medicare Promoting Interoperability Program Hardship Exception Application
Eligible hospitals and Critical Access Hospitals (CAH) may submit a Medicare Promoting Interoperability (Pl) Exception Application citing one of the following specified reasons for review and
approval:
• Using decertified EHRtechnology
• Insufficient Internet Connectivity
• Extreme and Uncontrollable Circumstances

0

Important dates and information

If you are an eligible hospital, you must submit an application by September 02, 2025 for CMSto process your hardship exception request for the 2026 payment adjustment. The
application will be available from May 1, 2025 - September 02, 2025.
If you are a CAH, you must submit an application by October 31, 2025 for CMSto process your hardship exception request the 2024 payment adjustment. The application will be
available from May 1, 2025 - October 31, 2025.
For additional support or if you have any questions, please contact the CCSQService Center at qnetsupport@cms.hhs.gov, call 866-288-8912 or CCSQSupport Central.

* Indicates required
*Which form would you like to complete today?

8

MedicarePl ProgramCriticalAccessHospital
* CAH CCN(6 Numeric digits only, example: 123456)
011300
CAH Legal name

0

WASHINGTONCOUNTYHEALTHCARE
AUTHORITY,INC

ApplicantInformation
Provide the information below for the person working on behalf of the Hospital or CAH.All return correspondencewill be sent to the contact listed in section Applicant Information.

* Submitter first name

Em
* Submitter last name
Smith
* CAHor Organization name
[ Critical Care Place
* Submitter email
[ em@gmail.com
* Confirm submitter email
[ em@gmail.com
* Submitter telephone number
7035551212
Extension
JO()()()()()(

* Address
123 Elm St
Suite/ apartment/ unit number

*city
Houston
State
Texas

0

*zipCode

0
■

..

77001

* I certify that I am authorized by the hospital identified

above to submit this application on behalf of the hospital.

Requestfor promotinginteroperabilityprogramhardshipexception
Reviewthe information below and indicate one hardship exception reason which makesthe Medicare Promoting Interoperability Program measuresnot applicable or available to your
practice.
Note: Only one hardship exception reason can be selected at this time.

* Hardship exception reason

8

Extremeand UncontrollableCircumstances
• Extreme and Uncontrollable Circumstances

0

Disaster
On behalf of the Hospital or CAH listed in this application, I am requesting this hardship exception and attest that the Hospital or CAHfaced Extreme and Uncontrollable
Circumstances in the form of a natural disaster in which the EHRsystem was damaged or destroyed, or the Hospital or CAHfaced Extreme and Uncontrollable Circumstances in the
form of a Health Pandemic. I further attest that this Extreme and Uncontrollable Circumstance in the constitutes a significant hardship in demonstrating meaningful use as defined

under: 42 CFR412.64 (d)(4)(ii)(B).
Period of time the EHRsystem was unavailable (MM/DD/YYYY)
to (MM/DD/YYYY).
• Start date

-

1111

• End date

-

1111

Certification statement for hardship application
NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete, or misleading information may be guilty of a criminal act
punishable under law and may be subject to civil penalties.

SIGNATUREOF HOSPITALREPRESENTATIVE
I certify that the information contained herein is true, accurate, and complete. I understand that the Medicare Promoting Interoperability Program Hardship Exception I requested may result
in a change in the amount the Hospital will be paid from Federal funds, and that by filling this application for a hardship exception I am submitting a claim for Federal funds, and the use of
any false claims, statements, or documents, or the concealment of a material fact used to obtain a Medicare Promoting Interoperability Program Hardship Exception, may be prosecuted
under applicable Federal or state criminal laws and may also be subject to civil penalties.
SUBMITTERWORKING ON BEHALFOF HOSPITAL(s}: I certify that I am submitting this application for a payment adjustment on behalf of the hospital(s) that has (have) given me authority
to act as agent. I understand that both the hospital(s) and I can be held personally responsible for all information entered.
I hereby agree to keep such records as are necessary to support the application submitted for a hardship exception of the Medicare Promoting Interoperability Program and to furnish those
records both in the application and at a future time upon request from the Department of Health and Human Services, or a contractor acting on their behalf.
No Medicare Promoting Interoperability Program hardship exception may be granted unless this application is completed and approved as required by existing law and regulations (42 CFR

§412.64Idi( 4)Iii)).
NOTICE:Anyone who misrepresents or falsifies essential information to receive payment from Federal funds requested by this application may upon conviction be subject to fine and
imprisonment under applicable Federal laws.
ROUTINE USE(S): Information from this Medicare Promoting Interoperability Program application for hardship exception and subsequently submitted information and documents may be
given to the Internal Revenue Service, private collection agencies, consumer reporting agencies in connection with recoupment of any overpayment made and to Congressional offices in
response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other Federal, state, local and foreign government agencies,
private business entities and individual providers of care, on matters relating to entitlement, fraud, Program abuse, Program integrity, and civil and criminal litigation in relation to the
operation of the Medicare Promoting Interoperability Program.
DISCLOSURES:While submission of information for this hardship exception application is voluntary, failure to provide necessary information for hospita I identification will result in delay in
processing the hardship exception application or may result in a denial.
It is mandatory that you tell us if you believe you have been overpaid under the Medicare Promoting Interoperability Program. The Social Security Act, Section 1128J, requires the reporting
and returning of overpayments.
By confirming this certification statement, I agree, and it is my intent, to sign this application and affirmation by including my name and the date below. I understand that completing the
information below is the legal equivalent of having placed my handwritten signature on the submitted application and this affirmation.

D

*certify statement for hardship

• Name of individual completing the form

D

I'm not a robot
reCAPTCHA
Privacy -Terms

Submit

Required information
Start date

l#t@i

WARNING:Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the Privacy Act of 1974.
Submission to the Hospital Hardship that contains Protected Health Information (PHI) and Personally Identifiable Information (PII) is a violation of these Acts. Questions containing PHI
will be deleted from the system and not processed. For detailed information regarding safeguarding protected healthcare information or data, please refer to the CMSQualityNet System
Privacy Policy.

INFORMATIONNOT TO BE RELEASED
TO PUBLIC UNLESSAUTHORIZEDBYLAW:This information is for internal Government use only and has not been publicly disclosed. It may contain
information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share Personally Identifiable Information (PII) and/or Protected Health
Information (PHI), Unauthorized disclosure may result in prosecution to the full extent of the law.

CMS.gov
Medicare Promoting Interoperability Program Hardship Exception Application
Eligible hospitals and Critical Access Hospitals (CAH) may submit a Medicare Promoting Interoperability (Pl) Exception Application citing one of the following specified reasons for review and
approval:
• Using decertified EHRtechnology
• Insufficient Internet Connectivity
• Extreme and Uncontrollable Circumstances

0

Important dates and information

If you are an eligible hospital, you must submit an application by September 02, 2025 for CMSto process your hardship exception request for the 2026 payment adjustment. The
application will be available from May 1, 2025 - September 02, 2025.
If you are a CAH,you must submit an application by October 31, 2025 for CMSto process your hardship exception request the 2024 payment adjustment. The application will be
available from May 1, 2025 - October 31, 2025.
For additional support or if you have any questions, please contact the CCSQService Center at qnetsupport@cms.hhs.gov, call 866-288-8912 or CCSQSupport Central.

* Indicates required
*Which form would you like to complete today?

8

MedicarePl ProgramCritical AccessHospital

* CAH CCN(6 Numeric digits only, example: 123456)
010001
CAH Legal name

I

0

HOUSTONCOUNTYHEALTHCARE
AUTHORITY

ApplicantInformation
Provide the information below for the person working on behalf of the Hospital or CAH.All return correspondence will be sent to the contact listed in section ApplicantInformation.

* Submitter first name

Em
* Submitter last name
Smith
* CAHor Organization name
[ Hope Hospital
* Submitter email
[ em@gmail.com
* Confirm submitter email
[ em@gmail.com
* Submitter telephone number
7035551212
Extension
JO()()()()()(

* Address
123 Elm St
Suite/ apartment/ unit number

*city
Houston

State
Texas

0

*zipCode

,. I

0
■

•

77001

* I certify that

,,

I am authorized by the hospital identified above to submit this application on behalf of the hospital.

Requestfor promotinginteroperabilityprogramhardshipexception
Reviewthe information below and indicate one hardship exception reason which makes the Medicare Promoting Interoperability Program measures not applicable or available to your
practice.
Note: Only one hardship exception reason can be selected at this time.

* Hardship exception reason

8

,,

Extremeand UncontrollableCircumstances
• Extreme and Uncontrollable Circumstances

0

Disaster
On behalf of the Hospital or CAH listed in this application, I am requesting this hardship exception and attest that the Hospital or CAHfaced Extreme and Uncontrollable
Circumstances in the form of a natural disaster in which the EHRsystem was damaged or destroyed, or the Hospital or CAHfaced Extreme and Uncontrollable Circumstances in the
form of a Health Pandemic. I further attest that this Extreme and Uncontrollable Circumstance in the constitutes a significant hardship in demonstrating meaningful use as defined
under: 42 CFR412.64 (d)(4)(ii)(B).
Period of time the EHRsystem was unavailable (MM/DD/YYYY)to (MM/DD/YYYY).
• Start date

-

1111
• End date

-

1111

Certification statement for hardship application
NOTICE:Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete, or misleading information may be guilty of a criminal act
punishable under law and may be subject to civil penalties.
SIGNATUREOF HOSPITAL REPRESENTATIVE
I certify that the information contained herein is true, accurate, and complete. I understand that the Medicare Promoting Interoperability Program Hardship Exception I requested may result
in a change in the amount the Hospital will be paid from Federal funds, and that by filling this application for a hardship exception I am submitting a claim for Federal funds, and the use of
any false claims, statements, or documents, or the concealment of a material fact used to obtain a Medicare Promoting Interoperability Program Hardship Exception, may be prosecuted
under applicable Federal or state criminal laws and may also be subject to civil penalties.

SUBMITTERWORKINGON BEHALFOF HOSPITAL(s}:I certify that I am submitting this application for a payment adjustment on behalf of the hospital(s) that has (have) given me authority
to act as agent. I understand that both the hospital(s) and I can be held personally responsible for all information entered.
I hereby agree to keep such records as are necessary to support the application submitted for a hardship exception of the Medicare Promoting Interoperability Program and to furnish those
records both in the application and at a future time upon request from the Department of Health and Human Services, or a contractor acting on their behalf.
No Medicare Promoting Interoperability Program hardship exception may be granted unless this application is completed and approved as required by existing law and regulations (42 CFR
§412.64 Idi( 4)Iii)).

NOTICE:Anyone who misrepresents or falsifies essential information to receive payment from Federal funds requested by this application may upon conviction be subject to fine and
imprisonment under applicable Federal laws.
ROUTINEUSE(S):Information from this Medicare Promoting Interoperability Program application for hardship exception and subsequently submitted information and documents may be
given to the Internal Revenue Service, private collection agencies, consumer reporting agencies in connection with recoupment of any overpayment made and to Congressional offices in
response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be made to other Federal, state, local and foreign government agencies,
private business entities and individual providers of care, on matters relating to entitlement, fraud, Program abuse, Program integrity, and civil and criminal litigation in relation to the
operation of the Medicare Promoting Interoperability Program.
DISCLOSURES:
While submission of information for this hardship exception application is voluntary, failure to provide necessary information for hospita I identification will result in delay in
processing the hardship exception application or may result in a denial.
It is mandatory that you tell us if you believe you have been overpaid under the Medicare Promoting Interoperability Program. The Social Security Act, Section 1128J, requires the reporting
and returning of overpayments.
By confirming this certification statement, I agree, and it is my intent, to sign this application and affirmation by including my name and the date below. I understand that completing the
information below is the legal equivalent of having placed my handwritten signature on the submitted application and this affirmation.

D

*certify statement for hardship

• Name of individual completing the form

D

I'm not a robot
reCAPTCHA
Privacy -Terms

Submit

Required information
Start date

l#t@i

WARNING:Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the Privacy Act of 1974.
Submission to the Hospital Hardship that contains Protected Health Information (PHI) and Personally Identifiable Information (PII) is a violation of these Acts. Questions containing PHI
will be deleted from the system and not processed. For detailed information regarding safeguarding protected healthcare information or data, please refer to the CMSQualityNet System
Privacy Policy.

INFORMATIONNOT TO BE RELEASEDTO PUBLIC UNLESSAUTHORIZEDBY LAW:This information is for internal Government use only and has not been publicly disclosed. It may contain
information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share Personally Identifiable Information (PII) and/or Protected Health
Information (PHI), Unauthorized disclosure may result in prosecution to the full extent of the law.