Information Collection

Waiver Requests (POs)

IC 223824 under ICR 202002-0938-002 · OMB 0938-1326.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1326 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10631 Waiver Requests (POs)	Form and Instruction
CMS-10631 PACE Application PACE Paper Application_01212020_FINAL.pdf	Form and Instruction

IC Title:

Waiver Requests (POs)

Agency IC Tracking Number:

CM-CPC

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.26

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-10631	PACE Application	PACE Paper Application_01212020_FINAL.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.