Use this form to request an exemption from participating in the HHCAHPS Survey for the CY 2028 Annual Payment Update (APU) period on the basis of your agency's size.

Before completing the online Participation Exemption Request (PER) form, home health agencies (HHAs) are encouraged to print this hardcopy form and use it as a worksheet to conduct the initial BEFORE entering the final count on the online form. Click here to review and print a hardcopy of the PER form.

When is the exemption in force? The exemption is in force only for the CY 2028 APU period which begins April 1, 2026. The exemption is good for one year only. Your agency must reapply if you want to request an exemption in future years.

Who can apply for the exemption? Your HHA can request an exemption if you served 59 or fewer HHCAHPS Survey eligible patients between April 1, 2025 and March 31, 2026. Every year, CMS reviews all participation exemption requests, along with other data, to determine whether your agency will receive an exemption.

What does the exemption mean? If based on this form, you believe that your HHA is exempt, you do not need to participate in the HHCAHPS Survey for the CY 2028 APU HHCAHPS Survey participation period.

What do I need to do? You need to provide a count of your agency's HHCAHPS Survey-eligible patients served between April 1, 2025 and March 31, 2026. The PER form below will help you do this. Please see the instructions below.

This form will assist you in determining if you have 59 or fewer HHCAHPS-eligible patients.

Instructions for Completing the PER Form:

• Step 1: Enter your 6-digit CCN (CMS Certification Number), which was formerly known as the Medicare Provider ID number. If your agency was recently certified by CMS and you have not yet received an active CCN, you will need to wait until a CCN is assigned and activated in CMS's systems before you can complete the online PER form.
  
  The system will automatically display the name of your agency (based on the CCN you enter in Step 1). If your agency name is different from the agency name that is displayed and the CCN you entered into the form is correct, please contact CMS.
• Step 2: Count and enter the number of patients served who were 17 years old or younger on the day of your count. These patients are not eligible to be included in the HHCAHPS Survey.
• Step 3: Count and enter the number of unduplicated (unique) patients served between April 1, 2025 and March 31, 2026 who were 18 years old and older whose care was covered by Medicare or Medicaid. Count patients who were discharged and later re-admitted for home care only once. Also, include patients enrolled in a Medicare Advantage plan or Medicaid managed care plan in this count, as their care is paid for by Medicare or Medicaid.
  
  To determine the number of unduplicated or unique patients served, count each patient only once regardless of the number of re-admissions during the specified 12-month period. Include both current and discharged patients in your count.
• Steps 4a through 4f: Of the patients included in the count in Step 3, enter the number of patients who fall into each of the categories in Steps 4a through 4f. These patients are not eligible to be included in the HHCAHPS Survey. Do not include a patient in more than one category.
  
  For example, if a patient who was served between April 1, 2025 and March 31, 2026 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 4e.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 4e.1 have been accounted for.
  
  Once you enter all counts, select the "Submit for Total Eligible" button to calculate your agency's total number of HHCAHP Survey-eligible patients.

1.	Enter your agency's 6-digit CMS Certification Number (CCN, formerly known as the Medicare Provider Number), then click the button beside the number that you entered.
	CCN Number:
	Agency Name:
	Agency name shown reflects information in the most current list of CMS agencies. Please contact CMS if this does not match your agency's name.
2.	Count and enter the number of patients served between April 1, 2025 and March 31, 2026 who were 17 years old or younger on the day of your count
3.	Count and enter the TOTAL number of UNDUPLICATED patients served between April 1, 2025 and March 31, 2026 who were 18 years old or older on the date of your count whose home care was paid for by Medicare or Medicaid (See instructions above for additional details on who to include.)
4.	Of the patients included in the count in Step 3, 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
	c.	Number of patients who received skilled home care between April 1, 2025 and March 31, 2026 for routine maternity care only
	d.	Number of patients who did not receive at least two (2) skilled care home visits between April 1, 2025 and March 31, 2026
	e1.	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
	e2.	In the text box below, provide a brief explanation that includes the number of patients and the relevant state laws/regulations that apply to all patients you have entered in step e.1 above.
	f.	Number of patients who at their initial contact with the agency, on their own initiative, said that the HHA may not release their name and any contact information to anyone other than the HHA 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 0938-1066. This information collection produces comparable data from home health agencies to help individuals choose an agency and improve care. The time required to complete this information collection is estimated to average less than 9 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory for qualifying home health agencies under 42 CFR §484.255(i) to meet program requirements and voluntary for survey respondents. Confidentiality is assured under 5 U.S.C. 552a (Privacy Act of 1974). 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 C1-25-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your survey, please email HomeHealthCAHPS@cms.hhs.gov.