1. Organization
1a. Organization Name:	1b. Medicare Provider Number:
1c. Mailing Address 1:	1d. Mailing Address 2:
1e. City:	1f. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Wash., D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Canada Northern Mariana Islands Puerto Rico Virgin Islands	1g. Zip Code: (xxxxx-xxxx)
1h. Telephone:     Ext.	Fax: (xxx-xxx-xxxx)	1i. Website:
2. Contact Person
2a. First Name:	2a. Middle Initial:	2a. Last Name:
2b. Title:	2c. Degree (e.g., RN, MD, PhD):
2d. Mailing Address 1:	2e. Mailing Address 2:
2f. City:	2g. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Wash., D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Canada Northern Mariana Islands Puerto Rico Virgin Islands	2h. Zip Code: (xxxxx-xxxx)
2i. Telephone:     Ext.	Fax: (xxx-xxx-xxxx)	2j. E-Mail:
3. Survey Vendor Organization This section is to be completed for hospitals using survey vendor to conduct the survey.
3a. Organization Name:
3b. Contact Person:
First Name:	Middle Initial:	Last Name:
3c. Title:	3d. Degree (e.g., RN, MD, PhD):
3e. Mailing Address 1:	3f. Mailing Address 2:
3g. City:	3h. State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Wash., D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Canada Northern Mariana Islands Puerto Rico Virgin Islands	3i. Zip Code: (xxxxx-xxxx)
3j. Telephone:   Ext.	Fax: (xxx-xxx-xxxx)	3k. E-Mail:

1. Exception Request For (check one in each box):
	New Exception Update of List of Applicable Hospitals Appeal of Exception Denial

Disproportionate Stratified Random Sampling Determination of Service Line Other Exception (specify)

2. List of hospitals applicable to this exception request This section is to be completed by survey vendors or hospitals administering the survey for multiple sites.

Do you currently have hospitals applicable to this exception request? YesNo

3. Description of Exception Request

3a. Purpose of Proposed Exception Requested (e.g., sampling, other):

3b. Rationale for Proposed Exception Requested:

3c. Explanation of Implementation of Proposed Exception Requested:

3d. Evidence that Exception Will Not Affect Results: