Information Collection

Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310

IC 8072 under ICR 202009-0938-008 · OMB 0938-0449.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0449 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-8003 Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310	Form and Instruction
Instructions_TechnicalGuide_V3.6.docx	Instruction
CMS-8003 Application for a Section 1915(c) Home and Community-Bas HCBSWaiverApp-v3.6January2019 (rev Sept 2020).docx	Form and Instruction
Crosswalk - HCBS Waiver Application (version 3.6).pdf Crosswalk - Waiver Application	IC Document
Crosswalk - HCBS Waiver Application (version 3.6) Instructions_Technical Guide_and Review Criteria.pdf Crosswalk - Application Instructions, Technical Guide, and Review Criteria	IC Document

IC Title:

Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 441.300-310 42 CFR 440.180

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-8003	Application for a Section 1915(c) Home and Community-Based Services Waiver	HCBSWaiverApp-v3.6January2019 (rev Sept 2020).docx		Yes	Yes	Fillable Fileable
Instruction			Instructions_TechnicalGuide_V3.6.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 49

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	71	71
Annual IC Time Burden (Hours)	6,005	6,005
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Waiver Application	Crosswalk - HCBS Waiver Application (version 3.6).pdf	09/24/2020
Crosswalk - Application Instructions, Technical Guide, and Review Criteria	Crosswalk - HCBS Waiver Application (version 3.6) Instructions_Technical Guide_and Review Criteria.pdf	09/24/2020

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