Information Collection

Medicare Waiver Demonstration Application

IC 43670 under ICR 201307-0938-025 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Ajpplication CMS-10069_Medicare_Demo_Waiver_App (Non-substantive changes).docx	Form and Instruction
crosswalk.doc Crosswalk	IC Document

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 Ajpplication	CMS-10069_Medicare_Demo_Waiver_App (Non-substantive changes).docx		Yes	Yes	Fillable Fileable

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
Crosswalk	crosswalk.doc	07/25/2013

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