Information Collection

Medicare Waiver Demonstration Application

IC 43670 under ICR 201009-0938-012 · OMB 0938-0880.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0880 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10069 Medicare Waiver Demonstration Application	Form and Instruction
CMS-10069 Medicare Waiver Demonstration Application CMS-10069 Medicare Demo Waiver App.pdf	Form and Instruction

IC Title:

Medicare Waiver Demonstration Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10069	Medicare Waiver Demonstration Application	CMS-10069 Medicare Demo Waiver App.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	6,000	6,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.