A. Hospital information
Hospital name, CCN, address, city, state and ZIP code, plus the person filing the report and the filer's phone number.
CMS-10455
Report of a Hospital Death Associated with Restraint or Seclusion
- Agency
- CMS
- Revision
- 2018-07-19
- Fillable fields
- 38
- Pages
- 1
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10455: Report of a Hospital Death Associated with Restraint or Seclusion
Form CMS-10455 is the Report of a Hospital Death Associated with Restraint or Seclusion from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. A hospital uses it to report a patient death tied to physical restraint, seclusion or a drug used as a restraint.
The form has three parts: hospital information with the hospital's CCN and the person filing the report, patient information including diagnoses and cause of death, and restraint information. In the restraint part, the form asks when the death happened in relation to the restraint or seclusion, which types were used, and the kind of physical restraint or the drug name and dosage.
The form carries OMB number 0938-1210 and estimates an average of 20 minutes per response. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-10455
B. Patient information
The patient's name, date of birth, primary diagnosis or diagnoses, medical record number, date of admission, date of death and cause of death.
C. Restraint information
Three timing choices, with the instruction to check only one: while in restraint or seclusion, within 24 hours of removal, or within 1 week where it contributed to the death.
Type of restraint
Check all that apply: Physical Restraint, Seclusion, or Drug Used as a Restraint.
Physical restraint types
A numbered list from 01 to 13, check all that apply, including side rails, two point and four point restraints, therapeutic holds, take-downs, enclosed beds, vest restraints and law enforcement restraints, with space to specify other physical holds.
Drug used as restraint
If a drug was used as a restraint, the drug name and the dosage.
The form is one page with three lettered sections.
How to fill out Form CMS-10455
- 1
Enter the hospital details
Fill in the hospital name, CCN and full address, then the name and phone number of the person filing the report.
- 2
Enter the patient details
Add the patient's name, date of birth, primary diagnoses, medical record number, admission date, date of death and cause of death.
- 3
Pick one timing choice
In Section C, the form says to check only one of the three choices about when the death happened.
- 4
Mark the types used
Check every type that applies. For physical restraint, check each numbered type that applies and specify any other physical hold.
- 5
Add drug details if any
If a drug was used as a restraint, write the drug name and the dosage.
- 6
Ask CMS where to submit
The form does not print a submission address. For questions about where to submit documents, it gives the email [email protected].
Why fill Form CMS-10455 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what the form says
Where to send it
The form does not list a mailing address for the report. It says to contact [email protected] with questions or concerns about where to submit documents.
Not to the PRA office
The CMS address in Baltimore printed at the bottom is for comments on the time estimate or the form. The form says not to send applications, claims, payments, medical records or other sensitive documents there.
OMB number and dates
The form shows OMB number 0938-1210 with an expiration date of 07/31/2021. The CMS page lists an OMB expiration date of 2026-01-31 and a revision date of 2018-07-19.
Time to complete
The form estimates an average of 20 minutes per response, including reviewing instructions, gathering the data and completing the form.
Related forms
Who uses Form CMS-10455?
The form is a hospital report. Section C names three situations it covers, and the form says to check only one.
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Questions about Form CMS-10455
What is Form CMS-10455?
It is the Report of a Hospital Death Associated with Restraint or Seclusion. It records the hospital, the patient, when the death happened in relation to restraint or seclusion, and the type of restraint used.
Which deaths does the form cover?
Section C lists three: a death while in restraint, seclusion or both; within 24 hours of removal of restraint, seclusion or both; or within 1 week, where restraint, seclusion or both contributed to the death. The form says to check only one.
Does the form cover drugs used as a restraint?
Yes. Drug Used as a Restraint is one of the types to check, and the form asks for the drug name and dosage.
Where do I send Form CMS-10455?
The form does not print a submission address. It says to contact [email protected] with questions or concerns about where to submit documents.
Can I send the report to the CMS address on the form?
The Baltimore address is for the PRA Reports Clearance Officer. The form says not to send applications, claims, payments, medical records or documents with sensitive information there.
How long does the form take?
The form estimates an average of 20 minutes per response.