Information Collection

Waiver Application

IC 222831 under ICR 201608-0938-002 · OMB 0938-1313.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1313 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10629 Waiver Application Form and Instruction
CMS-10629 Waiver Application for Providers and Suppliers Subject t CMS-10629.Waiver Application (DRAFT).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Waiver Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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-10629	Waiver Application for Providers and Suppliers Subject to an Enrollment Moratorium	CMS-10629.Waiver Application (DRAFT).pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	4,800	4,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.