Crosswalk

Revisions to Form CMS-10069 MEDICARE WAIVER DEMONSTRATION APPLICATION/UPDATE FORM

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reason for the Change
	1 and 3	Page 1: Header Information (before Section 1) Page 3: bottom of the page	Revise as follows:	Revision to demonstration web site URL as follows: http://www.medicarenhic.com is replaced by: http://med.noridianmedicare.com/web/ivig	Change in demonstration Implementation Support Contractor web site from NHIC to Noridian due to re-competition of DMEMAC JA contract. The phone number will stay the same.
	3	Text after Section V	Remove text referring to initial enrollment period	Revision of paragraph as follows: Replace: If you wish to participate, you must complete, sign and submit an application, as space and funding for this demonstration are limited. Both you and your physician must sign the application, and we must receive it no later than 5 p.m. Eastern time, 9/12/2014 for this initial enrollment period. With: If you wish to participate, you must complete, sign and submit an application, as space and funding for this demonstration are limited. Both you and your physician must sign the application.	Initial enrollment period ended in September 2014. Applications are being accepted on a rolling basis, so deadline is not relevant any more.
	3	Instructions for where to send application (After Section V)	Revise mailing addresses and fax numbers	Revision of mailing address: After: “You may mail your application to this address:”, replace: NHIC, Corp. IVIG Demo P.O. Box 9140 Hingham, MA. 02043-9140 With: Noridian Healthcare Solutions IVIG Demo PO Box 6788 Fargo ND 58108-6788 After: “For overnight delivery, mail your application to:” Replace: NHIC, Corp. IVIG Demo 75 Sgt. William Terry Dr. Hingham, MA. 02043 With: Noridian Healthcare Solutions IVIG Demo 900 42nd Street South Fargo ND 58103 After: “You can fax your completed application to:” Replace: 781-741-3533 With: 701-277-2428	Change in information about where to submit application due to change in implementation support contractor as a result of re-competition of DMEMAC JA contract.

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