Information Collection

1135 Waiver Request Automated Process

IC 243968 under ICR 202102-0938-013 · OMB 0938-1384.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1384 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10752 1135 Waiver Request Automated Process	Form and Instruction
CMS-10752 Waiver Inquiry Form 1135 Waiver-Inquiry Collection Instrument 2-9-21.pdf	Form and Instruction
CMS-10752 Waiver Inquiry Form 1135 Waiver-Inquiry Collection Instrument 2-9-21.pdf	Form and Instruction
CMS-10752 Helath Care Facility Status Collection Form Health Care Facility Status Collection Instrument 2-9-21.pdf	Form and Instruction
CMS-10752 Helath Care Facility Status Collection Form Health Care Facility Status Collection Instrument 2-9-21.pdf	Form and Instruction
1135 Inquiry Web Form RevisionTable.docx Inquiry Crosswalk	IC Document
1135 Inquiry Web Form RevisionTable.docx Inquiry Crosswalk	IC Document
1135 Waiver_Flexibility Request Form Revision Table.docx Waiver Flexibility Request Crosswalk	IC Document
1135 Waiver_Flexibility Request Form Revision Table.docx Waiver Flexibility Request Crosswalk	IC Document
1135 Healthcare Facility Status Form Revision Table.docx Healthcare Facility Form Crosswalk	IC Document
1135 Healthcare Facility Status Form Revision Table.docx Healthcare Facility Form Crosswalk	IC Document

IC Title:

1135 Waiver Request Automated Process

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-10752	Waiver Inquiry Form	1135 Waiver-Inquiry Collection Instrument 2-9-21.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10752	Helath Care Facility Status Collection Form	Health Care Facility Status Collection Instrument 2-9-21.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,730

Number of Respondents for Small Entity: 300

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,730	730	3,000
Annual IC Time Burden (Hours)	3,730	730	3,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Inquiry Crosswalk	1135 Inquiry Web Form RevisionTable.docx	02/16/2021
Waiver Flexibility Request Crosswalk	1135 Waiver_Flexibility Request Form Revision Table.docx	02/16/2021
Healthcare Facility Form Crosswalk	1135 Healthcare Facility Status Form Revision Table.docx	02/16/2021

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