Medicare Waiver Demonstration Application

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.