Waiver Requests (States)

The PACE Organization Application Process in 42 CFR Part 460 (CMS-10631)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1326 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10631 Waiver Requests (States) Form and Instruction
CMS-10631 PACE Application PACE Paper Application_01212020_FINAL.pdf Form and Instruction
CMS-10631 PACE Application PACE Paper Application_01212020_FINAL.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Waiver Requests (States)	Agency IC Tracking Number:	CM-CPC

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.26

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10631	PACE Application	PACE Paper Application_01212020_FINAL.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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