Use this form to request an exemption from participating in the OAS CAHPS survey for the calendar year (CY) 2026 Annual Payment Update (APU) period based on the number of eligible procedures. Click here to review and print a hardcopy of the PER form before entering the counts on the online form.

When is the exemption in force? The exemption is in force for the CY 2026 APU period, which is January 1 through December 31, 2024. The exemption is good for one year. Facilities must reapply to request an exemption annually.

Who can apply for the exemption? Hospital outpatient departments (HOPDs) that meet OAS CAHPS eligibility and served fewer than 60 OAS CAHPS survey-eligible patients between January 1 and December 31, 2023 can request an exemption. On an annual basis, CMS reviews all participation exemption requests and makes a determination to approve or deny.

What does the exemption mean? Exempt hospitals do not need to participate in the OAS CAHPS Survey for the CY 2026 APU OAS CAHPS Survey data collection period, which runs from January 1 through December 31, 2024.

This form will assist you in determining if you have fewer than 60 OAS CAHPS-eligible patients.

Instructions for Completing the Participation Exemption Request Form

• Step 1: enter the hospital's 6-digit CCN (CMS Certification Number).
• The system will display the hospital name associated with the CCN from Step 1. If the hospital name on record is incorrect, please contact your State Survey Agency.

• Step 2: enter the number of unduplicated (unique) patients served between January 1, 2023 and December 31, 2023, who were 18 years old and older who had an eligible surgery or procedure within the OAS CAHPS eligible range (i.e., CPT- 4¹ code in the 10004- 69990 range or the following G-codes: G0104, G0105, G0121 or G0260). Note that a list of excluded CPT codes that should not be included in the count can be found in the Protocol and Guidelines Manual Appendix P, available on the OAS CAHPS website (V8.1_OASCAHPS_ProtocolsGuidelinesManual.docx).

  Count all patients regardless of payment method (CMS, insurance, or other method of payment).

  To determine the number of unduplicated or unique patients served, count each patient only once regardless of the number of surgeries or procedures they received during the specified 12-month period.

  ¹ CPT only copyright 2024 American Medical Association. All rights reserved.

• Step 3: Of the patients included in the count in Step 2, enter the number of patients who fall into each of the categories in Steps 3a through 3g. These patients are not eligible to be included in the OAS CAHPS Survey. Do not include a patient in more than one category. For example, if a patient who was served between January 1, 2023 and December 31, 2023, was released to hospice, but you know that that patient is deceased, you would include that patient in the count of patients known to be deceased but not in the count of those discharged to hospice. For Step 3f.2, you must provide a brief description of the relevant state laws/regulations and the number of affected patients until all patients entered in Step 3f.1 have been accounted for.

1.	Enter 6-digit CMS Certification Number (CCN)
	CCN Number:
	Confirm the hospital name:
2.	Enter the TOTAL number of UNDUPLICATED (unique) patients served between January 1 and December 31, 2023, regardless of payment method, who were 18 years old or older and who received a surgery or procedure in the OAS CAHPS eligible range (see instructions above for eligible procedures)
3.	Of the patients included in Step 2, enter the number of patients who fall into the following categories. Do not include a patient in more than one of the following categories.
	a.	Number of patients who were known to be deceased as of the day of your count
	b.	Number of patients who were discharged to hospice or a psychiatric hospital following their surgery or procedure
	c.	Number of patients who reside in a nursing home
	d.	Number of patients who are prisoners
	e.	Number of patients who do not have a U.S. domestic mailing address
	f.1	Number of patients who have a condition or illness for which the state in which the patient resides has regulations or laws restricting the release of patient information for patients with those conditions
	f.2	In the text box below, provide a brief explanation that includes the relevant state laws/regulations that apply to all patients you have entered in step f.1 above.
	g.	Number of patients who at their initial contact with the hospital, on their own initiative, requested that the hospital protect their identity (i.e., they said that the hospital may not release their name or any contact information to anyone other than the hospital personnel). If you enter a number in this field, you may be requested to provide documentation to CMS.

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 0938-1240 with an expiration date of November 30, 2024. The time required to complete this information collection is estimated to average 8 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 21244-1850.