Form CMS-10752 CMS 1135 Waiver/Flexibility Request and Inquiry Form

CMS 1135 Waiver / Flexibility Request and Inquiry Form

Organization Workflow
CMS 1135 Waiver / Flexibility Request

CMS 1135 Waiver / Flexibility Request and Inquiry Form
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a voluntary information
collection. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence
not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Adriane
Saunders at [email protected].

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a
disaster or emergency. Blanket waivers prevent gaps in the access to care for beneficiaries affected by the emergency.
When a blanket waiver is issued, providers don't have to apply for an individual waiver. If there's no blanket waiver,
providers can ask for an individual Section 1135 waiver.
If you have a request or inquiry, please use this form to submit your request to CMS.

Who are you? ?
An Organization / Provider

A Beneficiary

What would you like to do?
I want to submit a waiver / flexibility request

I want to submit an inquiry request

Submit a waiver / flexibility request
1 Select a Public Health Emergency

Select the Public Health Emergency (PHE) that applies to your waiver request

Public Health Emergency (PHE) (required) *

?

Please select one
COVID-19

3/13/20 - 10/31/2020

California Wildfire

3/13/20 - 10/31/2020

Hurricane Laura

8/15/20 - 11/15/2020

Hurricane Revelation

9/13/19 - 12/13/2019

CA

2 Provide Your Contact Information
Some explanatory text on what’s in the step

Point of Contact

?

Who should CMS contact in response to this waiver request?

Email address

(required) *

First name (required) *

Last name (required) *

Phone number

Organization Information ?
Who is the organization making this request?

Organization name (required) *

State/US Territory/Federal District (required) *

Nebraska
NebraNebraskaska

Nevada

New York

Organization Categories

?

Who is the organization making this request?

General

Emergency Provider / Supplier Types

Other

Association

Part D Prescription Plan

Advocacy Group

State Government

Congressional Office

State Medicaid Agency

Corporation

State Survey Agency

Department of Health and Human
Services

Tribal Nation

General

Emergency Provider / Supplier Types

Other

Ambulatory Surgical Center (ASC)

Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)

Community Mental Health Center
(CMHC)

Nursing Homes (SNF/NF)

Comprehensive Outpatient
Rehabilitation Facility (CORF)

Organ Procurement Organization

Critical Access Hospital (CAH)

Outpatient Physical Therapy/Speech
Therapy (OPT/ST)

Community Mental Health Center
(CMHC)

Programs of All-Inclusive Care for
Elderly (PACE)

End Stage Renal Disease (ESRD)

Psychiatric Residential Treatment
Facility (PRTF)

Home Health Agencies (HHA)(OPO)

Religious Non-Medical Health Care
Institution (RNCHI)

Hospice(OPO)

Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)

Hospital

Transplant Center

General

Emergency Provider / Supplier Types

Ambulance

Palliative

Durable Medical Equipment (DME)

Physician

Lab

Other

Organization Identification Numbers

Other

?

What are the identification numbers for your organization?
These numbers will be different, depending on the categories you have
selected for your organization including: CCN/Provider, Medicare Contract
Number, or NPI.
For the categories selected above, use:

NAME-OF-IDENTIFICATION-NUMBER

3 Describe your 1135 Waiver / Flexibility Request

?

Select the type of request you are making. Depending on your request type, we may ask
you for additional information.

Request #1
Waiver Request Type (required) *

Regulation Related to this Request

?

Regulation Description (required) *

?

+ Add another waiver request

4 Submit your request

Submit

Confirmation Message (need content)
Case #

WARNING: Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the
Privacy Act of 1974. Submission to the 1135 Waivers System that contains Protected Health Information (PHI) is a violation of these Acts. Questions
containing PHI will be deleted from the system and not processed. For detailed information regarding transmitting or receiving healthcare information or
data read the QualityNet System Security Policy (PDF).

INFORMATION NOT TO BE RELEASED TO PUBLIC UNLESS AUTHORIZED BY LAW: This information is for internal Government use only and has not been
publicly disclosed. It may contain information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share
Publicly Identifiable Information (PII) and/or Public Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of the
law.

CMS 1135 Waiver / Flexibility Request and Inquiry Form

Organization Workflow
CMS 1135 Inquiry Request

CMS 1135 Waiver / Flexibility Request and Inquiry Form
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a voluntary information
collection. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence
not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Adriane
Saunders at [email protected].

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a
disaster or emergency. Blanket waivers prevent gaps in the access to care for beneficiaries affected by the emergency.
When a blanket waiver is issued, providers don't have to apply for an individual waiver. If there's no blanket waiver,
providers can ask for an individual Section 1135 waiver.
If you have a request or inquiry, please use this form to submit your request to CMS.

Who are you? ?
An Organization / Provider

A Beneficiary

What would you like to do?
I want to submit a waiver / flexibility request

I want to submit an inquiry request

Submit an inquiry
1 Select a Public Health Emergency

Select the Public Health Emergency (PHE) that applies to your inquiry request

Public Health Emergency (PHE) (required) *
California Wildfire

?

3/13/20 - 10/31/20

CA

2 Provide Your Contact Information
Some explanatory text on what’s in the step

Point of Contact

?

Who should CMS contact in response to this inquiry request?

Email address

(required) *

First name (required) *

Last name (required) *

Phone number

3 Inquiry
Inquirer Type (required) *
Please select an option

Inquiry Topic

(required) *

Please select an option

Inquiry Form

Submit

Confirmation Message (need content)

WARNING: Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the
Privacy Act of 1974. Submission to the 1135 Waivers System that contains Protected Health Information (PHI) is a violation of these Acts. Questions
containing PHI will be deleted from the system and not processed. For detailed information regarding transmitting or receiving healthcare information or
data read the QualityNet System Security Policy (PDF).

INFORMATION NOT TO BE RELEASED TO PUBLIC UNLESS AUTHORIZED BY LAW: This information is for internal Government use only and has not been
publicly disclosed. It may contain information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share
Publicly Identifiable Information (PII) and/or Public Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of the
law.

CMS 1135 Waiver / Flexibility Request and Inquiry Form

Beneficiary Workflow
CMS 1135 Inquiry Request

CMS 1135 Waiver / Flexibility Request and Inquiry Form
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a voluntary information
collection. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence
not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Adriane
Saunders at [email protected].

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a
disaster or emergency. Blanket waivers prevent gaps in the access to care for beneficiaries affected by the emergency.
When a blanket waiver is issued, providers don't have to apply for an individual waiver. If there's no blanket waiver,
providers can ask for an individual Section 1135 waiver.
If you have a request or inquiry, please use this form to submit your request to CMS.

Who are you? ?
An Organization / Provider

A Beneficiary

What would you like to do?
I want to submit a waiver / flexibility request

I want to submit an inquiry request

Submit an inquiry
1 Select a Public Health Emergency

Select the Public Health Emergency (PHE) that applies to your inquiry request

Public Health Emergency (PHE)
California Wildfire

?

3/13/20 - 10/31/20

CA

2 Provide Your Contact Information
Some explanatory text on what’s in the step

Point of Contact

?

Who should CMS contact in response to this inquiry request?

Email address

(required) *

First name (required) *

Last name (required) *

Phone number

3 Inquiry
Inquirer Type (required) *
Please select an option

Inquiry Topic

(required) *

Please select an option

Inquiry Form

Submit

Confirmation Message (need content)

WARNING: Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the
Privacy Act of 1974. Submission to the 1135 Waivers System that contains Protected Health Information (PHI) is a violation of these Acts. Questions
containing PHI will be deleted from the system and not processed. For detailed information regarding transmitting or receiving healthcare information or
data read the QualityNet System Security Policy (PDF).

INFORMATION NOT TO BE RELEASED TO PUBLIC UNLESS AUTHORIZED BY LAW: This information is for internal Government use only and has not been
publicly disclosed. It may contain information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share
Publicly Identifiable Information (PII) and/or Public Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of the
law.