Office of Health Care Statistics Request for Extension or Exemption Form

Per Utah Administrative Rule 428-2-10, the Office may grant exemptions or extensions from reporting requirements in Title R428 to data suppliers under certain circumstances.

Exemption: may be granted if a data supplier demonstrates that compliance imposes an unreasonable cost. Maximum, one year.

Extension: may be granted when the supplier demonstrates that technical or unforeseen difficulties prevent compliance. Maximum, 30 days.

For either case, please complete the form below and submit to our office for review and processing. We should have a decision to you within a few business days.

If you need to extend an existing, approved request, we must receive a new request in our office at least seven calendar days before the deadline.

Type of Request *
Extension Exemption
Type of request you are submitting here.
Reporting System *
All Payer Claims Database Healthcare Facilities Database CAHPS HEDIS Other
Month/Year/File Type(s) *
Data Supplier Name *

Name of the Organization applying for an extension or exemption.
Address *

Mailing address for the data supplier
Telephone Number * - ### - ### ####
Phone number of data supplier
Contact Person *

Name of contact person for this extension for exemption.
Email *

Email address of contact person.
Requested Time Period *

Time period you are requesting. Maximums: exemption, one year; extension, 30 days.
A description of the relief sought, including reference to specific sections or language of the requirement *
A statement of facts, reasons, or legal authority in support of the request *
A proposed alternative to the requirement or deadline *
Upload a File

Attach Files Attach Files

Please attach any other documentation that you would like us to consider as part of your request.