Waiver Application

Waiver Application for Providers and Suppliers Subject to an Enrollment Moratorium (CMS-10629)

OMB: 0938-1313

IC ID: 222831

Information Collection (IC) Details

View Information Collection (IC)

Waiver Application
 
No New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10629 Waiver Application for Providers and Suppliers Subject to an Enrollment Moratorium CMS-10629.Waiver Application (DRAFT).pdf Yes Yes Fillable Fileable Signable

Health Health Care Services

 

800 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 800 800 0 0 0 0
Annual IC Time Burden (Hours) 4,800 4,800 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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