Information Collection

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

IC 8072 under ICR 202202-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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 revised 12-30-21.pdf	Instruction
Instructions_TechnicalGuide_V3.6 revised 12-30-21.pdf	Instruction
CMS-8003 Application for a Section 1915(c) Home and Community-Bas Waiver Application (2022 version 2).pdf	Form and Instruction
CMS-8003 Application for a Section 1915(c) Home and Community-Bas Waiver Application (2022 version 2).pdf	Form and Instruction
1915(c) waiver app change crosswalk 12-29-21.xlsx Crosswalk - Waiver Application	IC Document
1915(c) waiver app change crosswalk 12-29-21.xlsx Crosswalk - Waiver Application	IC Document
Justification 1915(c) waiver app Jan 2022.pdf Crosswalk - Application Instructions, Technical Guide, and Review Criteria	IC Document
Justification 1915(c) waiver app Jan 2022.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	Waiver Application (2022 version 2).pdf		Yes	Yes	Fillable Fileable
Instruction			Instructions_TechnicalGuide_V3.6 revised 12-30-21.pdf		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	Previously Approved
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	1915(c) waiver app change crosswalk 12-29-21.xlsx	02/25/2022
Crosswalk - Application Instructions, Technical Guide, and Review Criteria	Justification 1915(c) waiver app Jan 2022.pdf	02/25/2022

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