CMS-10752 Helath Care Facility Status Collection Form

Submissions of 1135 Waiver Request Automated Process (CMS-10752)

Health Care Facility Status Collection Instrument 2-9-21

1135 Waiver Request Automated Process

OMB: 0938-1384

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CMS Healthcare Facility Status 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 0938-1384 (Expires 02/28/2021). 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].

Sometimes the normal operations of a healthcare provider are disrupted by emergencies or disasters. Please document the
current status of your organization including impact to beneficiaries.

What would you like to do?
I want to submit a waiver / flexibility request
I want to submit an inquiry request
I want to provide a status on my healthcare facility, patients and or residents

Provide a status update
1 Emergency Information
Type of emergency (required) *
Select the applicable emergency below. Picking one of these is required.

Public Health
Select the type of PHE
Emergency event
Select the type of event

2 Facility Information
Organization Information
Please provide the required information for your organization below.

Organization name (required) *

Organization category (required) *
Select an emergency provider or supplier type
Organization identification number/CMS Certification
Number (required) *

City (required) *

State/US Territory/Federal District (required) *
Select a state, territory, or district
ZIP code (required) *

Operational status
Select a status
Evacuation status
Select a status

Patient/Resident Information
Please provide the following information about your patients or residents in your facility.

Number of beds or stations (if applicable)

Number of patients/residents with injuries

Number of patient/resident fatalities

Facility census information
Please provide us with the details below regarding total number of patients or residents in your facility and their disposition when
applicable.

Census

Number of patients/residents evacuated

Number of patients/residents repatriated

Percentage of
patients/residents
evacuated:

--%

Percentage of
patients/residents
repatriated:

--%

Details of the Healthcare Facility Status (including anticipated needs during emergency) (required) *
i.e.10 residents evacuated to ABC nursing home; 5 residents evacuated to XYZ nursing home, Facility does not have running water...

Point of Contact
Please provide reliable contact information to minimize delay or disruption of direct communication and updates on
the facility's operational status.
Email address (required) *

Confirm email address (required) *

First name (required) *

Last name (required) *

Phone number

3 Impact to Facility
Please complete the following fields to notify us of your current status to facilitate the provision of aid from Federal
resources.
Structural damage?
Select for yes
Select the type of damage (required) *
There is an area below where you can describe the damage.
Minor damage
Major damage
Structure
Power loss?
Select for yes
Select the power loss type (required) *
Commercial
Generator
Generator type (required) *
Select the type of generator
Remaining fuel (required) *
Select the number of hours of remaining fuel
Mixed
Unknown
HVAC loss?
Select for yes
Select the HVAC loss type (required) *
Partial HVAC loss
Partial HVAC loss
Full loss of HVAC
Other impacts to facility
Water Outage
Sewer Outage
Telephone Outage
No Access (Road Closure)
Other
Describe the impact (required) *
i.e. Facility suffered structural damage to east wing, will need long term repairs, approximately 6 months....Electrical has been down
but crews are repairing, eta 2 days......

Submit

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 safeguarding protected healthcare information or
data, please refer to the HIPAA Security Rule.

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 Healthcare Facility Status Form

A federal government website managed and paid for by
the U.S. Centers for Medicare & Medicaid Services, 7500
Security Boulevard, Baltimore MD 21244

Modal, submission successful

Thank you! Your submission has been successful.
Your case number is 

You will also receive an email confirmation summarizing your emergency status submission and providing you
with additional guidance.

HCF Status Form open dropdown menus
Public Health Emergency (PHE)
Please select an option
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

Emergency event
Select the type of event
Hurricanes
Flooding
Wildfires
Mudslides
Tornadoes
Earthquakes
Volcanoes
Cyber Security
Pandemic Event (e.g., H1N1, COVID-19, etc.)
Fire
Power Outage
Chemical Spill
Nuclear or Biological Terrorist Attack
Shootings
Other

Organization category
Select an emergency provider or supplier type
Ambulatory Surgical Center (ASC)
Community Mental Health Center (CMHC)
Comprehensive Outpatient Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Community Mental Health Center (CMHC)
End Stage Renal Disease (ESRD)
Home Health Agencies (HHA)
Hospice
Hospital
Intermediate Care Facility for Individuals with Intellectual
Disabilities (ICF/IID)
Nursing Homes (SNF/NF)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech Therapy (OPT/ST)
Programs of All-Inclusive Care for Elderly (PACE)
Psychiatric Residential Treatment Facility (PRTF)
Religious Non-Medical Health Care Institution (RNCHI)
Rural Health Clinic/Federally Qualified Health Center (RHC/
FQHC)
Transplant Center
Other

State/US Territory/Federal District
Select a state, territory, or district
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces America
Armed Forces Europe
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
US Virgin islands
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming

Operational status
Select a status
Fully Open
Partially Open
Closed
Unknown

Evacuation status
Select a status
Evacuated
Shelter in Place (SIP)
Relocated
Unknown

Generator type
Select the type of generator
Diesel
Gasoline
Propane
Natural
Combination
Unknown

Remaining fuel
Select the number of hours of remaining fuel
Less than 24 hours
24 to 48 hours
48 to 72 hours
72 to 96 hours
More than 96 hours
Unknown

HCF Status Form open help text information
What would you like to do?

Choose the applicable option below.

I want to submit a waiver / flexibility request

I want to submit an inquiry request

If a public health emergency (PHE) has been declared
by the President and the Secretary of Health and
Human Services, you may request an 1135 waiver for
certain CMS requirements by selecting this option

When there’s a disaster or emergency, waivers and
flexibilities help health care facilities
give timely care to as many people who’ve been
affected as possible. This means we’re helping
States, Federal Districts and U.S. territories to make
sure people with Medicare and/or Medicaid
continue to have access to care.

I want to provide a status update on my patients and/or healthcare facility residents

Public Health

This option should be used when the President and
the Secretary of the Department of Health and
Human Services (HHS), under Section 319 of the
Public Health Service (PHS) Act has declared a Public
Health Emergency (PHE).

Select the type of PHE
Please select an option
Emergency event

You may use this option to report any
impact on normal operations.

This option should be used if your facility has been
impacted by an emergency event that has not been
declared a PHE.

Organization Information

An organization is an organized body of people with a
particular purpose (e.g., Corporation, Health System,
Please provide the required information foretc.).
your organization below.

Organization category (required) *
Select an emergency provider or supply

This provides CMS additional information on the type
of organization providing this healthcare facility status
type
information.

Organization identification number/CMS Certification
Indicate the applicable identification number for the
Number (required) *
healthcare facility/provider affiliated with your
organization impacted by the emergency event.

Point of Contact

CMS uses your contact information to send responses
and ask follow up questions.

Please provide reliable contact information to minimize delay or disruption of direct communication and updates on a
facility's operational status.

3 Impact to Facility

Physical, electrical, power, environmental, etc. impacts
to facility.

Please complete the following fields to notify us of your current status to facilitate the provision of aid from Federal
resources.


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