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pdfCMS 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 0938-1384 (Expires 05/31/2024). 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].
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
?
?
I want to provide a status update on my beneficiaries and/or healthcare facility
?
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.
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
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019
(COVID-19)
03/13/2020 - 07/16/2022
2 Provide Your Contact Information
This will help keep you updated on your request’s progress
Point of Contact
?
Who should CMS contact in response to this waiver request?
Email address
(required) *
Confirm email address
(required) *
First name (required) *
Last name (required) *
Phone number
(XXX)XXX-XXXX
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
(required) *
?
Who is the organization making this request?
General
Emergency Provider / Supplier Types
Other
Advocacy Group
State Government
Association
Qualified Health Plan
Corporation
State Medicaid or CHIP Agency
Medicare Advantage / Part D Plan
State Survey Agency
General
Emergency Provider / Supplier Types
Tribal Nation
Other
Ambulatory Surgical Center (ASC)
Nursing Homes (SNF/NF)
Community Mental Health Center
(CMHC)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech
Therapy (OPT/ST)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Programs of All-Inclusive Care for
Elderly (PACE)
End Stage Renal Disease (ESRD)
Psychiatric Residential Treatment
Facility (PRTF)
Home Health Agencies (HHA)
Religious Non-Medical Health Care
Institution (RNCHI)
Hospice
Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)
Hospital
Transplant Center
Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)
General
Emergency Provider / Supplier Types
Ambulance
Palliative
Durable Medical Equipment (DME)
Physician
Lab
Other
Organization Identification Numbers
Other
Other Organization Category
?
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:
IDENTIFICATION NUMBER
Separate multiple identification numbers with a comma.
3 Describe your 1135 Waiver / Flexibility Request
Request #1
Waiver Request Type (required) *
?
Click here if you do not see your Waiver Request Type
Regulation Related to this Request
?
Request Description
?
(required) *
Detail a brief summary of why the waiver is needed (For example: CAH is sole community provider
without reasonable transfer options at this point during the specified emergent event (e.g. flooding, tornado,
fires, or flu outbreak). CAH needs a waiver to exceed its bed limit by X number of beds for Y days/weeks (be
specific)) and the type of relief you are seeking.
+ Add another waiver request
4 Submit your request
Submit
Thank You! Your request has been successfully submitted.
Your case number is
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.
To report technical issues please email [email protected] and note “1135 Waiver/Flexibility” in the subject line.
If you are requesting an 1135 waiver or making an Inquiry about a public health emergency, please submit your request at
the CMS PHE Emergency Web Portal. For all other questions, please contact [email protected].
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" (https://www.hhs.gov/hipaa/for-professionals/index.html).
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
Personally Identifiable Information (PII) and/or Protected Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of
the law.
CMS 1135 Waiver/Flexibility Request and Inquiry
A federal government website managed and paid for by
the U.S Centers for Medicare & Medicaid Services. 7500
Security Boulevard, Baltimore MD 21244
Drop down options
PHE
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019 (COVID-19)
03/13/2020 - 07/16/2022
State/US Territory/Federal 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
Waiver/Flexibility Request Type
Accelerated Advanced Payment
Accreditation Organizations: Survey, Certification, Quality and Enforcement
Acute Care Hospital (ACH) Patient in Excluded Distinct Part Units
Acute Care Hospitals (ACH) with Distinct Part Inpatient Psychiatric Units
Alternate Treatment Sites
Ambulance
Ambulance Services - Medicare Ground Ambulance Data Collection System
Ambulance Services - Ambulance Treat in Place
Ambulatory Surgery Center (ASC): Survey, Certification, Quality and Enforcement
Ambulatory Surgical Center (ASC): Payment
Annual Wellness Visit (AWV)
ASCs - Medical Staff
ASCs - Nursing Services
Bankruptcy
Beneficiaries Notices & Signature Requirements
Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital: Allows IPPS and other acute care
hospitals that need to relocate inpatients from psychiatric unit to an acute care bed and unit
Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital: Allows IPPS and other acute care
hospitals that need to relocate inpatients from rehabilitation unit to an acute care bed and unit
Care for Patients in Extended Neoplastic Disease Care Hospitals
Care for Patients in Extended Neoplastic Disease Care Hospitals - Comprehensive Care for Joint Replacement (CJR) Model
Certification
Certified Nursing Assistants: Survey, Certification, Quality and Enforcement
Clinical Laboratory Improvement Amendments (CLIA): Survey, Certification, Quality and Enforcement
CMHS - Quality assessment and performance improvement (QAPI)
CMHS - Provision of Services
CMHS - 40 Percent Rule
Community Health Center (CHC): Payment
Community Mental Health Center (CHC): Payment
Community Mental Health Center (CHC): Survey, Certification, Quality and Enforcement
Comprehensive Outpatient Rehabilitation facilities (CORF): Payment
Comprehensive Outpatient Rehabilitation facilities (CORF): Survey, Certification, Quality and Enforcement
Conditions of Participation (COP)
Cost Reports
Critical Access Hospital (CAH): Survey, Certification, Quality and Enforcement
Critical Access Hospital (CAH): Waive the requirements that limit the number of beds to 25 and the length of stay to 96
hours
Critical Access Hospital (CAH): Payment
Diabetes Self-Management: Payment
Diabetes Self-Management: Survey, Certification, Quality and Enforcement
Durable Medical Equipment (DME): If lost, destroyed, irreparably damaged or otherwise rendered unusable, waive
requirements such that face-to-face requirements, a new physician’s order and new medical necessity doc
Eligible Practitioners
Emergency Preparedness
EMTALA: Payment
EMTALA: Survey, Certification, Quality and Enforcement
End Stage Renal Disease (ESRD): Payment
End Stage Renal Disease (ESRD): Survey, Certification, Quality and Enforcement
Ensuring Correct Processing of Home Health Disaster Related Claims: Allow MACs to extend auto-cancellation date of
Requests for Anticipated Payment (RAPs) during emergencies
ESRD Facilities - Training Program and Periodic Audits
ESRD Facilities - Defer Equipment Maintenance & Fire Safety Inspections
ESRD Facilities - Emergency Preparedness
ESRD Facilities - Ability to Delay Some Patient Assessments
ESRD Facilities - Time Period for Initiation of Care Planning and Monthly Physician Visits
ESRD Facilities - Dialysis Home Visits to Assess Adaptation and Home Dialysis Machine Designation
ESRD Facilities - Home Dialysis Machine Designation – Clarification
ESRD Facilities - Special Purpose Renal Dialysis Facilities (SPRDF) Designation Expanded
ESRD Facilities - Dialysis Patient Care Technician (PCT) Certification
ESRD Facilities - Transferability of Physician Credentialing
ESRD Facilities - Expanding Availability of Renal Dialysis Services to ESRD Patients - Furnishing Dialysis Services on the
Main Premises
ESRD Facilities - Clarification for Billing Procedures
Evaluation and Management: Payment
Exhaustion of Part A Benefits
Extended Repayment Schedule for Overpayments
Extension for Inpatient Prospective Payment System (IPPS) Wage Index Revisions
Extension for Inpatient Prospective Payment System (IPPS) Wage Index Revisions: Allows Hospital Wage Index development
Time Table for hospitals to request revisions
Extension for Medicare Geographic Classification Review Board (MGCRB) Applications: Allows an extension to the deadline
of application re-classification requirements
Federally Qualified Health Center (FQHC): Payment
Federally Qualified Health Center (FQHC): Survey, Certification, Quality and Enforcement
Flexibility for Medicare Telehealth Services - Eligible Practitioners
Flexibility for Medicare Telehealth Services - Audio-Only Telehealth for Certain Services
Flexibility for Inpatient Rehabilitation Facilities Regarding the “60 Percent Rule”
HHAs - Initial Assessments
HHAs - Waive Onsite Visits for HHA Aide Supervision
HHAs - Allow OTs, PTs, and SLPs to Perform Initial and Comprehensive Assessment for all Patients
HHAs - 12-hour Annual In-service Training Requirement for Home Health Aides
HHAs - Detailed Information Sharing for Discharge Planning for Home Health Agencies
HHAs - Clinical Records
HHAs - Training and Assessment of Aides
HHAs - Quality Assurance and Performance Improvement (QAPI)
Home Health Agency (HHA): Timeframe for OASIS transmission
Home Health Agency (HHA): Payment
Home Health Agency (HHA): Survey, Certification, Quality and Enforcement
Home Infusion Therapy: Payment
Home Infusion Therapy: Survey, Certification, Quality and Enforcement
Hospice: Payment
Hospice: Survey, Certification, Quality and Enforcement
Hospice - Waive Requirement for Hospices to Use Volunteers
Hospice - Comprehensive Assessments
Hospice - Waive Non-Core Services
Hospice - Waived Onsite Visits for Hospice Aide Supervision
Hospice - Hospice Aide Competency Testing Allow Use of Pseudo Patients
Hospice - 12 hour Annual In-service Training Requirement for Hospice Aides
Hospice - Annual Training
Hospital Inpatient: Payment
Hospital Outpatient: Payment
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - EMTALA
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Verbal Orders
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Reporting Requirements
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Patient Rights [Only for hospitals that are
considered to be impacted by a widespread outbreak of COVID-19]
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Sterile Compounding
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Detailed Information Sharing for Discharge
Planning for Hospitals and CAHs
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Limiting Detailed Discharge Planning for Hospitals
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Medical Staff
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Medical Records
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Flexibility inPatient Self Determination Act
Requirements (Advance Directives)
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Physical Environment
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Telemedicine
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Physician Services
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Anesthesia Services
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Utilization Review
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Written Policies and Procedures for Appraisal of
Emergencies at Off Campus Hospital Departments [With respect to surge facilities only]
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Emergency Preparedness Policies and Procedures
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Quality Assessment and Performance
Improvement Program
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Nursing Services
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Food and Dietetic Services
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Respiratory Care Services
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Expanded Ability for Hospitals to Offer Long-term
Care Services (“Swing-Beds”) for Patients Who do not Require Acute Care but do Meet the Skilled Nursing Facility (SNF)
Level of Care Criteria as Set Forth at 42 CFR 409.31
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Medicare Graduate Medical Education (GME)
Affiliation Agreement
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - CAH Personnel Qualifications
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - CAH Staff Licensure
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - CAH Status and Location
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Temporary Expansion Locations
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Responsibilities of Physicians in CAHs
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - Long Term Care Hospitals - Site Neutral Payment
Rate Provisions
Hospitals, Psych. Hospitals, and CAHs, including Cancer Ctrs and LTCHs - CoP for COVID-19 Vaccinations
Hospitals Classified as Sole Community Hospitals (SCHs)
Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (MDHs)
Hospital: Survey, Certification, Quality and Enforcement
Housing Acute Care Patients in Excluded Distinct Part Units: Allows the authority to house acute care inpatients in excluded
distinct part units (where appropriate)
ICF/IID - Staffing Flexibilities
ICF/IID - Suspension of Community Outings
ICF/IID - Suspend Mandatory Training Requirements
ICF/IID - Modification of Adult Training Programs and Active Treatment
Inpatient Rehab Facility (IRF): Survey, Certification, Quality and Enforcement
Inpatient Rehab Facility (IRF): Payment
Inpatient Rehabilitation Facility – Intensity of Therapy Requirement (“3-Hour Rule”)
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID): Survey, Certification, Quality and
Enforcement
Intermediate Care Facility (ICF): Payment
Lab: Payment
Level of Care Requirement
Life Safety Code (LSC)
Long Term Care Hospital (LTCH) Benefit Requirements
LTC Facilities and SNFs and/or NFs - PASRR
LTC Facilities and SNFs and/or NFs - Physical Environment
LTC Facilities and SNFs and/or NFs - Resident Groups
LTC Facilities and SNFs and/or NFs - Training and Certification of Nurse Aides
LTC Facilities and SNFs and/or NFs - Physician Visits in Skilled Nursing Facilities/Nursing Facilities
LTC Facilities and SNFs and/or NFs - Resident Roommates and Grouping
LTC Facilities and SNFs and/or NFs - Resident Transfer and Discharge
LTC Facilities and SNFs and/or NFs - Physician Services - Physician Delegation of Tasks in SNFs
LTC Facilities and SNFs and/or NFs - Physician Services - Physician Visits
LTC Facilities and SNFs and/or NFs - Physician Services - Note to Facilities
LTC Facilities and SNFs and/or NFs - Quality Assurance and Performance Improvement (QAPI)
LTC Facilities and SNFs and/or NFs - In-Service Training
LTC Facilities and SNFs and/or NFs - Detailed Information Sharing for Discharge Planning for Long-Term Care (LTC) Facilities
LTC Facilities and SNFs and/or NFs - Clinical Records
LTC Facilities and SNFs and/or NFs - Paid Feeding Assistants
Medicare Appeals in Fee for Service (FFS), Medicare Advantage (MA) and Part D
Medicare Provider Locations (Billing)
Medicare Telehealth
Minimum Data Set (MDS): Payment
Minimum Data Set (MDS): Survey, Certification, Quality and Enforcement
Modification of 60-Day Limit for Substitute Billing Arrangements (Locum Tenens)
Nursing Homes (SNF/NF): Survey, Certification, Quality and Enforcement
OASIS: Payment
OASIS: Survey, Certification, Quality and Enforcement
Organ Procurement Organizations: Survey, Certification, Quality and Enforcement
Outpatient Physical Therapy/Outpatient Speech Pathology: Payment
Outpatient Physical Therapy/Outpatient Speech Pathology: Survey, Certification, Quality and Enforcement
Part A or B Appeals
Part A or B Claims Processing
Part A or B Authorizations
Part A or B Provider Audits
Part A or B Provider Licensure Requirements
Part A or B Provider Locations (Billing)
Part A or B Provider: Payment
Part B Drug Coverage
Part B Drug Payment
Part B Outpatient Claims
Part B Outpatient: Payment
Physical Environment for Multiple Providers/Suppliers - Inspection, Testing & Maintenance (ITM) under the Physical
Environment Conditions of Participation - Specific Physical Environment Waiver Information
Portable X-Ray: Payment
Portable X-Ray: Survey, Certification, Quality and Enforcement
Preadmission Screen and Resident Review (PASARR): Survey, Certification, Quality and Enforcement
Practitioner Locations
Provider Enrollment Requirements
Psychiatric Residential Treatment Facility (PRTF): Payment
Psychiatric Residential Treatment Facility (PRTF): Survey, Certification, Quality and Enforcement
Religious Nonmedical Health Care Institution Coverage (RNHCI): Payment
Religious Nonmedical Health Care Institution Coverage (RNHCI): Survey, Certification, Quality and Enforcement
RHCs and FQHCs - Certain Staffing Requirements
RHCs and FQHCs - Physician Supervision of NPs in RHCs and FQHCs
RHCs and FQHCs - Temporary Expansion Locations
Rural Health Clinic: Payment
Rural Health Clinic: Survey, Certification, Quality and Enforcement
Safety
Skilled Nursing Facility (SNF): 3-day Prior Hospitalization
Skilled Nursing Facility (SNF): For beneficiaries who exhausted their SNF benefits, renewed SNF coverage without first
having to start a new benefit period
Skilled Nursing Facility (SNF): Timeframe for MDS assessments and transmission
Special Enrollment Period
Specific LSC for Multiple Providers - Waiver Information - Alcohol-based Hand-Rub (ABHR) Dispensers
Supporting Care for Patients in LTCHs
Specific LSC for Multiple Providers - Waiver Information - Fire Drills
Specific LSC for Multiple Providers - Waiver Information - Temporary Construction
Transplant: Patient Care
Transplant: Payment
Transplant: Survey, Certification, Quality and Enforcement
Waiver of provider conditions to allow for provisions of services in alternative settings
Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.
What would you like to do?
Choose the applicable option below.
I want to submit a waiver / flexibility request 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.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those
impacted by an emergency or disaster.
I want to submit an inquiry request 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
You may use this option to report any impact on normal operations.
Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.
Provide Your Contact Information - Point of Contact
CMS uses your contact information to send responses and ask follow up questions.
Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.
Organization Information - State/US Territory/Federal District dropdown
Choose all applicable States, US Territories and/or Federal Districts where your healthcare facilities are located.
Provide Your Contact Information - Organization Categories
This provides CMS additional information on the type of organization requesting a waiver. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).
Provide Your Contact Information - Organization Identification Numbers
Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your
organization impacted by the PHE.
Describe Your 1135 Waiver / Flexibility Request
CMS uses this information to route your request to the appropriate area for faster response.
Describe Your 1135 Waiver / Flexibility Request - Waiver / Flexibility Request Type
dropdown
Start typing key words for your request. A list of waiver option(s) that match your key word(s) will
appear to choose from.
Describe Your 1135 Waiver / Flexibility Request - Regulation Related to this Request
dropdown
Cite the regulation(s) you are requesting be waived (if applicable).
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 0938-1384 (Expires 05/31/2024). 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].
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
?
?
I want to provide a status update on my beneficiaries and/or healthcare facility
?
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) *
Please select one
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019
(COVID-19)
03/13/2020 - 07/16/2022
2 Provide Your Contact Information
This will help keep you updated on your request’s progress
Point of Contact
?
Who should CMS contact in response to this inquiry request?
Email address
(required) *
Confirm email address
(required) *
First name (required) *
Last name (required) *
?
Zip Code (required) *
XXXXX
Phone number
(XXX)XXX-XXXX
Organization Information ?
Who is the organization making this request?
Organization Name (required) *
Organization Categories
(required) *
?
Who is the organization making this request?
Emergency Provider / Supplier Types
General
Other
Advocacy Group
State Government
Association
Qualified Health Plan
Corporation
State Medicaid or CHIP Agency
Medicare Advantage / Part D Plan
State Survey Agency
Emergency Provider / Supplier Types
General
Tribal Nation
Other
Ambulatory Surgical Center (ASC)
Nursing Homes (SNF/NF)
Community Mental Health Center
(CMHC)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech
Therapy (OPT/ST)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Programs of All-Inclusive Care for
Elderly (PACE)
End Stage Renal Disease (ESRD)
Psychiatric Residential Treatment
Facility (PRTF)
Home Health Agencies (HHA)
Religious Non-Medical Health Care
Institution (RNCHI)
Hospice
Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)
Hospital
Transplant Center
Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)
Emergency Provider / Supplier Types
General
Ambulance
Palliative
Durable Medical Equipment (DME)
Physician
Lab
Other
Organization Identification Numbers
Other
Other Organization Category
?
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:
IDENTIFICATION NUMBER
Separate multiple identification numbers with a comma.
3 Inquiry
Request #1
Topic
(required) *
?
Please select an option
Type
(required) *
?
Please select an option
Click here if you do not see your type
Description
(required) *
Provide a comprehensive description of your inquiry (including regulation citations if applicable).
+ Add another inquiry request
4 Submit Your Inquiry
Submit
Thank You! Your request has been successfully submitted.
Your case number is
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.
To report technical issues please email [email protected] and note “1135 Waiver/Flexibility” in the
subject line.
If you are requesting an 1135 waiver or making an Inquiry about a public health emergency, please submit
your request at the CMS PHE Emergency Web Portal. For all other questions, please contact
[email protected].
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"" (https://www.hhs.gov/hipaa/for-professionals/index.html).
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
A federal government website managed and paid for by
the U.S Centers for Medicare & Medicaid Services. 7500
Security Boulevard, Baltimore MD 21244
Drop down options
PHE
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019 (COVID-19)
03/13/2020 - 07/16/2022
Topic
Medicaid/CHIP
Original Medicare (Part A or B)
Medicare Advantage/Prescription Drug Plan
Qualified Health Plans
Type
638 Tribal Clinics
Original Medicare (Part A or B)
Academia
Medicare Advantage/Prescription Drug Plan
Access To Care
Qualified Health Plans
Advocate
Ambulance
Ambulatory Care Center
Appeals
Appendix K
Association/Society for Provider/Facility
Attorney for Provider/Facility
Billing Agency
Consultant for Provider/Facility
Critical Access Hospital
Denials
Dialysis Facility
Eligibility
Employer
Facility
Fair Hearings
Federal/State Government Agency
Federally Qualified Health Center (FQHC)
General Public
HCBS Waivers
Home Health
Hospice
Hospital
Insurance Company
Long Term Care Services And Supports
Managed Care
Medical Supplier/DME
Nurse/Nurse Practitioner
Nursing Home
Other
Payment Methodology/Rates
Pharmacist/Pharmacy
Physical/Occupational Therapy
Physician
Physician Assistant
Provider – Mental Health
Provider - Other
Provider Enrollment
Respite
Retainer Payments
Rural Health Clinic
Rural Health Clinic (RHC)
Skilled Nursing Facility
State Agency
Telehealth
Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.
What would you like to do?
Choose the applicable option below.
I want to submit a waiver / flexibility request 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.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of
those impacted by an emergency or disaster.
I want to submit an inquiry request 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
You may use this option to report any impact on normal operations.
Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.
Point of Contact
CMS uses your contact information to send responses and ask follow up questions.
Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.
Zip Code
Please enter your 5 digit zip code.
Organization Categories
This provides CMS additional information on the type of organization requesting a inquiry. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).
Organization Identification Numbers
Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your
organization impacted by the PHE.
Inquiry - Type dropdown
Choose your inquiry type from the dropdown list.
Inquiry - Topic dropdown
Choose from the dropdown list which category your inquiry would fall under.
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 0938-1384 (Expires 05/31/2024). 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].
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
?
?
I want to provide a status update on my beneficiaries and/or healthcare facility
?
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) *
Please select one
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019
(COVID-19)
03/13/2020 - 07/16/2022
2 Provide Your Contact Information
This will help keep you updated on your request’s progress
Point of Contact
?
Who should CMS contact in response to this inquiry request?
Email address
(required) *
Confirm email address
(required) *
First name (required) *
Last name (required) *
?
Zip Code (required) *
XXXXX
Phone number
(XXX)XXX-XXXX
Organization Information ?
Who is the organization making this request?
Organization Name (required) *
Organization Categories
(required) *
?
Who is the organization making this request?
Emergency Provider / Supplier Types
General
Other
Advocacy Group
State Government
Association
Qualified Health Plan
Corporation
State Medicaid or CHIP Agency
Medicare Advantage / Part D Plan
State Survey Agency
Emergency Provider / Supplier Types
General
Tribal Nation
Other
Ambulatory Surgical Center (ASC)
Nursing Homes (SNF/NF)
Community Mental Health Center
(CMHC)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech
Therapy (OPT/ST)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Programs of All-Inclusive Care for
Elderly (PACE)
End Stage Renal Disease (ESRD)
Psychiatric Residential Treatment
Facility (PRTF)
Home Health Agencies (HHA)
Religious Non-Medical Health Care
Institution (RNCHI)
Hospice
Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)
Hospital
Transplant Center
Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)
Emergency Provider / Supplier Types
General
Ambulance
Palliative
Durable Medical Equipment (DME)
Physician
Lab
Other
Organization Identification Numbers
Other
Other Organization Category
?
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:
IDENTIFICATION NUMBER
Separate multiple identification numbers with a comma.
3 Inquiry
Request #1
Topic
(required) *
?
Please select an option
Type
(required) *
?
Please select an option
Click here if you do not see your type
Description
(required) *
Provide a comprehensive description of your inquiry (including regulation citations if applicable).
+ Add another inquiry request
4 Submit Your Inquiry
Submit
Thank You! Your request has been successfully submitted.
Your case number is
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.
To report technical issues please email [email protected] and note “1135 Waiver/Flexibility” in the
subject line.
If you are requesting an 1135 waiver or making an Inquiry about a public health emergency, please submit
your request at the CMS PHE Emergency Web Portal. For all other questions, please contact
[email protected].
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"" (https://www.hhs.gov/hipaa/for-professionals/index.html).
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
A federal government website managed and paid for by
the U.S Centers for Medicare & Medicaid Services. 7500
Security Boulevard, Baltimore MD 21244
Drop down options
PHE
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019 (COVID-19)
03/13/2020 - 07/16/2022
Topic
Medicaid/CHIP
Original Medicare (Part A or B)
Medicare Advantage/Prescription Drug Plan
Qualified Health Plans
Type
638 Tribal Clinics
Original Medicare (Part A or B)
Academia
Medicare Advantage/Prescription Drug Plan
Access To Care
Qualified Health Plans
Advocate
Ambulance
Ambulatory Care Center
Appeals
Appendix K
Association/Society for Provider/Facility
Attorney for Provider/Facility
Billing Agency
Consultant for Provider/Facility
Critical Access Hospital
Denials
Dialysis Facility
Eligibility
Employer
Facility
Fair Hearings
Federal/State Government Agency
Federally Qualified Health Center (FQHC)
General Public
HCBS Waivers
Home Health
Hospice
Hospital
Insurance Company
Long Term Care Services And Supports
Managed Care
Medical Supplier/DME
Nurse/Nurse Practitioner
Nursing Home
Other
Payment Methodology/Rates
Pharmacist/Pharmacy
Physical/Occupational Therapy
Physician
Physician Assistant
Provider – Mental Health
Provider - Other
Provider Enrollment
Respite
Retainer Payments
Rural Health Clinic
Rural Health Clinic (RHC)
Skilled Nursing Facility
State Agency
Telehealth
Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.
What would you like to do?
Choose the applicable option below.
I want to submit a waiver / flexibility request 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.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of
those impacted by an emergency or disaster.
I want to submit an inquiry request 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
You may use this option to report any impact on normal operations.
Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.
Point of Contact
CMS uses your contact information to send responses and ask follow up questions.
Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.
Zip Code
Please enter your 5 digit zip code.
Organization Categories
This provides CMS additional information on the type of organization requesting a inquiry. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).
Organization Identification Numbers
Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your
organization impacted by the PHE.
Inquiry - Type dropdown
Choose your inquiry type from the dropdown list.
Inquiry - Topic dropdown
Choose from the dropdown list which category your inquiry would fall under.
CMS 1135 Waiver / Flexibility Request and Inquiry Form
Organization Workflow
CMS 1135 Waiver / Flexibility Request
Medicaid waiver submission
Standard waiver
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 0938-1384 (Expires 05/31/2024). 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].
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
?
?
I want to provide a status update on my beneficiaries and/or healthcare facility
?
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.
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
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019
(COVID-19)
03/13/2020 - 07/16/2022
2 Provide Your Contact Information
This will help keep you updated on your request’s progress
Point of Contact
?
Who should CMS contact in response to this waiver request?
Email address
(required) *
Confirm email address
(required) *
First name (required) *
Last name (required) *
Phone number
(XXX)XXX-XXXX
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
?
(required) *
Who is the organization making this request?
Emergency Provider / Supplier Types
General
Other
Advocacy Group
State Government
Association
Qualified Health Plan
Corporation
State Medicaid or CHIP Agency
Medicare Advantage / Part D Plan
State Survey Agency
Emergency Provider / Supplier Types
General
Tribal Nation
Other
Ambulatory Surgical Center (ASC)
Nursing Homes (SNF/NF)
Community Mental Health Center
(CMHC)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech
Therapy (OPT/ST)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Programs of All-Inclusive Care for
Elderly (PACE)
End Stage Renal Disease (ESRD)
Psychiatric Residential Treatment
Facility (PRTF)
Home Health Agencies (HHA)
Religious Non-Medical Health Care
Institution (RNCHI)
Hospice
Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)
Hospital
Transplant Center
Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)
Emergency Provider / Supplier Types
General
Other
Ambulance
Palliative
Durable Medical Equipment (DME)
Physician
Lab
Other
Other Organization Category
Background
Under section 1135 of the Social Security Act (the Act), the Secretary has the authority to temporarily
waive or modify certain Medicare, Medicaid, and CHIP requirements to ensure that sufficient health
care items and services are available to meet the needs of enrollees in an area affected by a federallydeclared PHE. Section 1135 authority enables providers to furnish needed items and services in good
faith during times of a PHE or disaster and be reimbursed and exempted from sanctions (absent any
determination of fraud or abuse).
Please select all that apply
I want to submit a general waiver
I want to submit a Medicaid / CHIP waiver
Please click the above option to request a Medicaid / CHIP waiver. For all other waivers, use the ‘general waiver’ option.
Medicaid or CHIP State Contact Information
?
This is contact information for official CMS communications
State Official title
(required) *
This is the Medicaid or CHIP designee for official CMS communications
State Agency name (required) *
State Official first name
(required) *
State Official last name
(required) *
State Official suffix
Examples, including JD, MD, PhD, RN
State Agency address
(required) *
Address 2
City
(required) *
State/US Territory/Federal District
Zip code
(required) *
(required) *
XXXXX
State Agency email address
(required) *
Confirm State Agency email address
(required) *
3 Describe your 1135 Medicaid Waiver / Flexibility Request
Please note that unless otherwise indicated in the descriptions below, flexibilities operationalized under section 1135 authority
terminate at the conclusion of the PHE.
Request #1
?
Waiver Request Type (required) *
Clinic Facility Requirement - Allow provision of services via telehealth
Click here if you do not see your Waiver Request Type
?
Description of Waiver Request
Pursuant to section 1135 (b)(1) (B) of the Act, permits the state and clinic to temporarily designate a clinic practitioner’s
location as part of the clinic facility only to the extent necessary so that clinic services may be provided via telehealth
when neither the patient nor practitioner is physically onsite at the clinic. Services provided via telehealth in clinic
practitioners’ homes (or another location) will be considered to be provided at the clinic - 42 C.F.R. § 440.90(a)
+ Add another waiver request
4 Submit your request
Submit
To report technical issues please email [email protected] and note “1135 Waiver/Flexibility” in the
subject line.
If you are requesting an 1135 waiver or making an Inquiry about a public health emergency, please submit
your request at the CMS PHE Emergency Web Portal. For all other questions, please contact
[email protected].
Thank You! Your request has been successfully submitted.
Your Medicaid / CHIP waiver case number is
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.
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" (https://www.hhs.gov/hipaa/for-professionals/index.html).
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
Personally Identifiable Information (PII) and/or Protected Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of
the law.
A federal government website managed and paid for by
the U.S Centers for Medicare & Medicaid Services. 7500
Security Boulevard, Baltimore MD 21244
CMS 1135 Waiver/Flexibility Request and Inquiry
Drop down options
PHE
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019 (COVID-19)
03/13/2020 - 07/16/2022
State/US Territory/Federal 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
Medicaid Waiver/Flexibility Request Types
Medicaid Authorizations-Suspend fee-for-service prior authorizations
Medicaid Authorizations-Extend pre-existing authorizations
Long Term Services and Supports (LTSS)-PASRR
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(c)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(i)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(k)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-HCBS services in approved 1115 Demonstration
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(c)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(i)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(k)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-HCBS services in approved 1115 Demonstration
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(c)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(i)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(k)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-HCBS services in
approved 1115 Demonstration
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Initial Evaluation
of Need
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Reevaluation
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Review and
Revision of Person-Centered Service Plan
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Initial
Evaluation of 1915(i) Eligibility
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Reevaluation
of 1915(i) Eligibility
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Initial
Independent Assessment of Need
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service PlansReassessments of Need
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Review and
Revision of the Person-Centered Service Plan
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Use of Representatives
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Initial Assessments
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Annual Reviews
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Use of Representatives
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Initial Assessments
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Annual Reassessments
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Person-Centered Service Plan Reviews
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Level of Care Determinations
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Level of Care Redeterminations
Fee for Service and Eligibility Fair Hearings-Extend fair hearing request timelines
Fee for Service and Eligibility Fair Hearings-Extend timelines for reinstatement of benefits
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify timelines to resolve appeals
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify state fair hearings timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify continuation of benefits timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify authorization decision timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify adverse benefit appeals filing timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify standard appeals timelines
Provider Enrollment-Waive application fees
Provider Enrollment-Waive criminal background checks
Provider Enrollment-Waive site visits
Provider Enrollment-Allow out-of-state provider reimbursement
Provider Enrollment-Pause revalidation deadlines
Provider Enrollment-Waive licensing requirements
Home Health State Plan Services Timeframe (Face-to-Face Encounters)
Use of Legally Responsible Individuals to Render Personal Care Services
Targeted Case Management Timeline - Monitoring and Follow-Up Activities
Private Duty Nursing-Modify practitioner requirements
Private Duty Nursing-Modify supervision requirements
Clinic Facility Requirement-Allow provision of clinic services via telehealth
Clinic Facility Requirement-Allow provision of clinic services in alternative settings
Physician Direction-Allow clinic services to be directed by other licensed professionals
Physician Direction-Allow inpatient psychiatric services for under 21 to be directed by other licensed professionals
Other Section 1135 Waiver Flexibilities
Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.
What would you like to do?
Choose the applicable option below.
I want to submit a waiver / flexibility request 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.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those
impacted by an emergency or disaster.
I want to submit an inquiry request 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
You may use this option to report any impact on normal operations.
Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.
Provide Your Contact Information - Point of Contact
CMS uses your contact information to send responses and ask follow up questions.
Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.
Organization Information - State/US Territory/Federal District dropdown
Choose all applicable States, US Territories and/or Federal Districts where your healthcare facilities are located.
Provide Your Contact Information - Organization Categories
This provides CMS additional information on the type of organization requesting a waiver. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).
Provide Your Contact Information - Medicaid or CHIP State Contact Information
This is the Medicaid or CHIP designee for official CMS communications.
Describe Your 1135 Medicaid Waiver / Flexibility Request
CMS uses this information to route your request to the appropriate area for faster response.
Describe Your 1135 Waiver / Flexibility Request - Waiver Request Type dropdown
CMS uses this information to route your request to the appropriate area for faster response.
Describe Your 1135 Medicaid Waiver / Flexibility Request - Description of Waiver Request
drop down
This description is auto-populated based on waiver type selected above. If this does not meet your needs, please select
“Click here if you do not see your Waiver Request Type” and enter your Waiver Request Type.
CMS 1135 Waiver / Flexibility Request and Inquiry Form
Organization Workflow
CMS 1135 Waiver / Flexibility Request
Medicaid waiver submission
Standard waiver with additonal information
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 0938-1384 (Expires 05/31/2024). 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].
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
?
?
I want to provide a status update on my beneficiaries and/or healthcare facility
?
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.
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
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019
(COVID-19)
03/13/2020 - 07/16/2022
2 Provide Your Contact Information
This will help keep you updated on your request’s progress
Point of Contact
?
Who should CMS contact in response to this waiver request?
Email address
(required) *
Confirm email address
(required) *
First name (required) *
Last name (required) *
Phone number
(XXX)XXX-XXXX
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
?
(required) *
Who is the organization making this request?
Emergency Provider / Supplier Types
General
Other
Advocacy Group
State Government
Association
Qualified Health Plan
Corporation
State Medicaid or CHIP Agency
Medicare Advantage / Part D Plan
State Survey Agency
Emergency Provider / Supplier Types
General
Tribal Nation
Other
Ambulatory Surgical Center (ASC)
Nursing Homes (SNF/NF)
Community Mental Health Center
(CMHC)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech
Therapy (OPT/ST)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Programs of All-Inclusive Care for
Elderly (PACE)
End Stage Renal Disease (ESRD)
Psychiatric Residential Treatment
Facility (PRTF)
Home Health Agencies (HHA)
Religious Non-Medical Health Care
Institution (RNCHI)
Hospice
Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)
Hospital
Transplant Center
Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)
Emergency Provider / Supplier Types
General
Other
Ambulance
Palliative
Durable Medical Equipment (DME)
Physician
Lab
Other
Other Organization Category
Background
Under section 1135 of the Social Security Act (the Act), the Secretary has the authority to temporarily
waive or modify certain Medicare, Medicaid, and CHIP requirements to ensure that sufficient health
care items and services are available to meet the needs of enrollees in an area affected by a federallydeclared PHE. Section 1135 authority enables providers to furnish needed items and services in good
faith during times of a PHE or disaster and be reimbursed and exempted from sanctions (absent any
determination of fraud or abuse).
Please select all that apply
I want to submit a general waiver
I want to submit a Medicaid / CHIP waiver
Please click the above option to request a Medicaid / CHIP waiver. For all other waivers, use the ‘general waiver’ option.
Medicaid or CHIP State Contact Information
?
This is contact information for official CMS communications
State Official title
(required) *
This is the Medicaid or CHIP designee for official CMS communications
State Agency name (required) *
State Official first name
(required) *
State Official last name
(required) *
State Official suffix
Examples, including JD, MD, PhD, RN
State Agency address
(required) *
Address 2
City
(required) *
State/US Territory/Federal District
Zip code
(required) *
(required) *
XXXXX
State Agency email address
(required) *
Confirm State Agency email address
(required) *
3 Describe your 1135 Medicaid Waiver / Flexibility Request
Please note that unless otherwise indicated in the descriptions below, flexibilities operationalized under section 1135 authority
terminate at the conclusion of the PHE.
Request #1
?
Waiver Request Type (required) *
Physician Direction - Allow clinic services to be directed by other licensed professionals
Click here if you do not see your Waiver Request Type
Description of Waiver Request
?
Pursuant to section 1135 (b) (1) (B) of the Act, allows the provisions of clinic services without the direction of a
physician or dentist - 42 C.F.R. §440.90.
Additional Information
(required) *
Please list the licensed professionals the state intends to approve to direct care.
+ Add another waiver request
4 Submit your request
Submit
To report technical issues please email [email protected] and note “1135 Waiver/Flexibility” in the
subject line.
If you are requesting an 1135 waiver or making an Inquiry about a public health emergency, please submit
your request at the CMS PHE Emergency Web Portal. For all other questions, please contact
[email protected].
Thank You! Your request has been successfully submitted.
Your Medicaid / CHIP waiver case number is
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.
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" (https://www.hhs.gov/hipaa/for-professionals/index.html).
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
Personally Identifiable Information (PII) and/or Protected Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of
the law.
CMS 1135 Waiver/Flexibility Request and Inquiry
A federal government website managed and paid for by
the U.S Centers for Medicare & Medicaid Services. 7500
Security Boulevard, Baltimore MD 21244
Drop down options
PHE
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019 (COVID-19)
03/13/2020 - 07/16/2022
State/US Territory/Federal 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
Medicaid Waiver/Flexibility Request Types
Medicaid Authorizations-Suspend fee-for-service prior authorizations
Medicaid Authorizations-Extend pre-existing authorizations
Long Term Services and Supports (LTSS)-PASRR
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(c)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(i)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(k)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-HCBS services in approved 1115 Demonstration
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(c)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(i)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(k)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-HCBS services in approved 1115 Demonstration
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(c)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(i)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(k)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-HCBS services in
approved 1115 Demonstration
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Initial Evaluation
of Need
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Reevaluation
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Review and
Revision of Person-Centered Service Plan
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Initial
Evaluation of 1915(i) Eligibility
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Reevaluation
of 1915(i) Eligibility
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Initial
Independent Assessment of Need
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service PlansReassessments of Need
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Review and
Revision of the Person-Centered Service Plan
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Use of Representatives
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Initial Assessments
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Annual Reviews
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Use of Representatives
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Initial Assessments
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Annual Reassessments
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Person-Centered Service Plan Reviews
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Level of Care Determinations
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Level of Care Redeterminations
Fee for Service and Eligibility Fair Hearings-Extend fair hearing request timelines
Fee for Service and Eligibility Fair Hearings-Extend timelines for reinstatement of benefits
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify timelines to resolve appeals
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify state fair hearings timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify continuation of benefits timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify authorization decision timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify adverse benefit appeals filing timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify standard appeals timelines
Provider Enrollment-Waive application fees
Provider Enrollment-Waive criminal background checks
Provider Enrollment-Waive site visits
Provider Enrollment-Allow out-of-state provider reimbursement
Provider Enrollment-Pause revalidation deadlines
Provider Enrollment-Waive licensing requirements
Home Health State Plan Services Timeframe (Face-to-Face Encounters)
Use of Legally Responsible Individuals to Render Personal Care Services
Targeted Case Management Timeline - Monitoring and Follow-Up Activities
Private Duty Nursing-Modify practitioner requirements
Private Duty Nursing-Modify supervision requirements
Clinic Facility Requirement-Allow provision of clinic services via telehealth
Clinic Facility Requirement-Allow provision of clinic services in alternative settings
Physician Direction-Allow clinic services to be directed by other licensed professionals
Physician Direction-Allow inpatient psychiatric services for under 21 to be directed by other licensed professionals
Other Section 1135 Waiver Flexibilities
Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.
What would you like to do?
Choose the applicable option below.
I want to submit a waiver / flexibility request 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.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those
impacted by an emergency or disaster.
I want to submit an inquiry request 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
You may use this option to report any impact on normal operations.
Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.
Provide Your Contact Information - Point of Contact
CMS uses your contact information to send responses and ask follow up questions.
Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.
Organization Information - State/US Territory/Federal District dropdown
Choose all applicable States, US Territories and/or Federal Districts where your healthcare facilities are located.
Provide Your Contact Information - Organization Categories
This provides CMS additional information on the type of organization requesting a waiver. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).
Provide Your Contact Information - Medicaid or CHIP State Contact Information
This is the Medicaid or CHIP designee for official CMS communications.
Describe Your 1135 Waiver / Flexibility Request - Waiver Request Type dropdown
CMS uses this information to route your request to the appropriate area for faster response.
Describe Your 1135 Medicaid Waiver / Flexibility Request - Description of Waiver Request
drop down
This description is auto-populated based on waiver type selected above. If this does not meet your needs, please select
“Click here if you do not see your Waiver Request Type” and enter your Waiver Request Type.
CMS 1135 Waiver / Flexibility Request and Inquiry Form
Organization Workflow
CMS 1135 Waiver / Flexibility Request
Medicaid waiver submission
Other waiver type
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 0938-1384 (Expires 05/31/2024). 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].
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
?
?
I want to provide a status update on my beneficiaries and/or healthcare facility
?
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.
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
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019
(COVID-19)
03/13/2020 - 07/16/2022
2 Provide Your Contact Information
This will help keep you updated on your request’s progress
Point of Contact
?
Who should CMS contact in response to this waiver request?
Email address
(required) *
Confirm email address
(required) *
First name (required) *
Last name (required) *
Phone number
(XXX)XXX-XXXX
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
?
(required) *
Who is the organization making this request?
Emergency Provider / Supplier Types
General
Other
Advocacy Group
State Government
Association
Qualified Health Plan
Corporation
State Medicaid or CHIP Agency
Medicare Advantage / Part D Plan
State Survey Agency
Emergency Provider / Supplier Types
General
Tribal Nation
Other
Ambulatory Surgical Center (ASC)
Nursing Homes (SNF/NF)
Community Mental Health Center
(CMHC)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech
Therapy (OPT/ST)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Programs of All-Inclusive Care for
Elderly (PACE)
End Stage Renal Disease (ESRD)
Psychiatric Residential Treatment
Facility (PRTF)
Home Health Agencies (HHA)
Religious Non-Medical Health Care
Institution (RNCHI)
Hospice
Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)
Hospital
Transplant Center
Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)
Emergency Provider / Supplier Types
General
Other
Ambulance
Palliative
Durable Medical Equipment (DME)
Physician
Lab
Other
Other Organization Category
Background
Under section 1135 of the Social Security Act (the Act), the Secretary has the authority to temporarily
waive or modify certain Medicare, Medicaid, and CHIP requirements to ensure that sufficient health
care items and services are available to meet the needs of enrollees in an area affected by a federallydeclared PHE. Section 1135 authority enables providers to furnish needed items and services in good
faith during times of a PHE or disaster and be reimbursed and exempted from sanctions (absent any
determination of fraud or abuse).
Please select all that apply
I want to submit a general waiver
I want to submit a Medicaid / CHIP waiver
Please click the above option to request a Medicaid / CHIP waiver. For all other waivers, use the ‘general waiver’ option.
Medicaid or CHIP State Contact Information
?
This is contact information for official CMS communications
State Official title
(required) *
This is the Medicaid or CHIP designee for official CMS communications
State Agency name (required) *
State Official first name
(required) *
State Official last name
(required) *
State Official suffix
Examples, including JD, MD, PhD, RN
State Agency address
(required) *
Address 2
City
(required) *
State/US Territory/Federal District
Zip code
(required) *
(required) *
XXXXX
State Agency email address
(required) *
Confirm State Agency email address
(required) *
3 Describe your 1135 Medicaid Waiver / Flexibility Request
Please note that unless otherwise indicated in the descriptions below, flexibilities operationalized under section 1135 authority
terminate at the conclusion of the PHE.
Request #1
?
Waiver Request Type (required) *
Click here if you do not see your Waiver Request Type
Please add only one waiver request in this field. Additional Waiver Requests not in the drop-down menu can be submitted by clicking "Add another waiver request" below.
Description of Waiver Request
(required) *
?
Please provide a description of the additional Medicaid 1135 waiver or modification requested by the state or territory.
Applicable Regulation
(required) *
Please include the regulatory citation(s) associated with this request.
+ Add another waiver request
4 Submit your request
Submit
To report technical issues please email [email protected] and note “1135 Waiver/Flexibility” in the
subject line.
If you are requesting an 1135 waiver or making an Inquiry about a public health emergency, please submit
your request at the CMS PHE Emergency Web Portal. For all other questions, please contact
[email protected].
Thank You! Your request has been successfully submitted.
Your Medicaid / CHIP waiver case number is
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.
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" (https://www.hhs.gov/hipaa/for-professionals/index.html).
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
Personally Identifiable Information (PII) and/or Protected Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of
the law.
CMS 1135 Waiver/Flexibility Request and Inquiry
A federal government website managed and paid for by
the U.S Centers for Medicare & Medicaid Services. 7500
Security Boulevard, Baltimore MD 21244
Drop down options
PHE
New Mexico Wildfires
xx/xx/xxxx - xx/xx/xxxx
Coronavirus Disease 2019 (COVID-19)
03/13/2020 - 07/16/2022
State/US Territory/Federal 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
Medicaid Waiver/Flexibility Request Types
Medicaid Authorizations-Suspend fee-for-service prior authorizations
Medicaid Authorizations-Extend pre-existing authorizations
Long Term Services and Supports (LTSS)-PASRR
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(c)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(i)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-1915(k)
Long Term Services and Supports (LTSS)-HCBS Settings Requirements-HCBS services in approved 1115 Demonstration
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(c)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(i)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-1915(k)
Long Term Services and Supports (LTSS)-Conflict of Interest Requirements-HCBS services in approved 1115 Demonstration
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(c)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(i)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-1915(k)
Long Term Services and Supports (LTSS)-Person-Centered Plan Beneficiary and Provider Signatures-HCBS services in
approved 1115 Demonstration
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Initial Evaluation
of Need
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Reevaluation
Long Term Services and Supports (LTSS)-1915(c) Level of Care and Person-Centered Service Plan Timelines-Review and
Revision of Person-Centered Service Plan
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Initial
Evaluation of 1915(i) Eligibility
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Reevaluation
of 1915(i) Eligibility
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Initial
Independent Assessment of Need
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service PlansReassessments of Need
Long Term Services and Supports (LTSS)-1915(i) Evaluations, Assessments and Person-Centered Service Plans-Review and
Revision of the Person-Centered Service Plan
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Use of Representatives
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Initial Assessments
Long Term Services and Supports (LTSS)-1915(j) State Plan Benefit-Annual Reviews
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Use of Representatives
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Initial Assessments
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Annual Reassessments
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Person-Centered Service Plan Reviews
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Level of Care Determinations
Long Term Services and Supports (LTSS)-1915(k) State Plan Benefit-Level of Care Redeterminations
Fee for Service and Eligibility Fair Hearings-Extend fair hearing request timelines
Fee for Service and Eligibility Fair Hearings-Extend timelines for reinstatement of benefits
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify timelines to resolve appeals
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify state fair hearings timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify continuation of benefits timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify authorization decision timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify adverse benefit appeals filing timelines
Managed Care Appeals, Fair Hearings, and Continuation of Benefits-Modify standard appeals timelines
Provider Enrollment-Waive application fees
Provider Enrollment-Waive criminal background checks
Provider Enrollment-Waive site visits
Provider Enrollment-Allow out-of-state provider reimbursement
Provider Enrollment-Pause revalidation deadlines
Provider Enrollment-Waive licensing requirements
Home Health State Plan Services Timeframe (Face-to-Face Encounters)
Use of Legally Responsible Individuals to Render Personal Care Services
Targeted Case Management Timeline - Monitoring and Follow-Up Activities
Private Duty Nursing-Modify practitioner requirements
Private Duty Nursing-Modify supervision requirements
Clinic Facility Requirement-Allow provision of clinic services via telehealth
Clinic Facility Requirement-Allow provision of clinic services in alternative settings
Physician Direction-Allow clinic services to be directed by other licensed professionals
Physician Direction-Allow inpatient psychiatric services for under 21 to be directed by other licensed professionals
Other Section 1135 Waiver Flexibilities
Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.
What would you like to do?
Choose the applicable option below.
I want to submit a waiver / flexibility request 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.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those
impacted by an emergency or disaster.
I want to submit an inquiry request 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
You may use this option to report any impact on normal operations.
Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.
Provide Your Contact Information - Point of Contact
CMS uses your contact information to send responses and ask follow up questions.
Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.
Organization Information - State/US Territory/Federal District dropdown
Choose all applicable States, US Territories and/or Federal Districts where your healthcare facilities are located.
Provide Your Contact Information - Organization Categories
This provides CMS additional information on the type of organization requesting a waiver. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).
Provide Your Contact Information - Medicaid or CHIP State Contact Information
This is the Medicaid or CHIP designee for official CMS communications.
Describe Your 1135 Waiver / Flexibility Request - Waiver Request Type dropdown
CMS uses this information to route your request to the appropriate area for faster response.
Describe Your 1135 Medicaid Waiver / Flexibility Request - Description of Waiver Request
drop down
This description is auto-populated based on waiver type selected above. If this does not meet your needs, please select
“Click here if you do not see your Waiver Request Type” and enter your Waiver Request Type.
CMS 1135 Waiver / Flexibility Request and Inquiry Form
Organization Workflow
CMS 1135 Waiver / Flexibility Request
COVID-19 PHE
Medicaid waiver
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 0938-1384 (Expires 05/31/2024). 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].
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
?
?
I want to provide a status update on my beneficiaries and/or healthcare facility
?
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.
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) *
Coronavirus Disease 2019
(COVID-19)
03/13/2020 - 07/16/2022
2 Provide Your Contact Information
This will help keep you updated on your request’s progress
Point of Contact
?
Who should CMS contact in response to this waiver request?
Email address
(required) *
Confirm email address
(required) *
First name (required) *
Last name (required) *
Phone number
(XXX)XXX-XXXX
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
(required) *
?
Who is the organization making this request?
General
Emergency Provider / Supplier Types
Other
Advocacy Group
State Government
Association
Qualified Health Plan
Corporation
State Medicaid or CHIP Agency
Medicare Advantage / Part D Plan
State Survey Agency
General
Emergency Provider / Supplier Types
Tribal Nation
Other
Ambulatory Surgical Center (ASC)
Nursing Homes (SNF/NF)
Community Mental Health Center
(CMHC)
Organ Procurement Organization (OPO)
Outpatient Physical Therapy/Speech
Therapy (OPT/ST)
Comprehensive Outpatient
Rehabilitation Facility (CORF)
Critical Access Hospital (CAH)
Programs of All-Inclusive Care for
Elderly (PACE)
End Stage Renal Disease (ESRD)
Psychiatric Residential Treatment
Facility (PRTF)
Home Health Agencies (HHA)
Religious Non-Medical Health Care
Institution (RNCHI)
Hospice
Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)
Hospital
Transplant Center
Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)
General
Emergency Provider / Supplier Types
Ambulance
Palliative
Durable Medical Equipment (DME)
Physician
Lab
Other
Other
Other Organization Category
This portal cannot be utilized for Covid-19-PHE related Medicaid 1135
waiver submissions.
This portal cannot be utilized for Covid-19-PHE related Medicaid 1135 waiver submissions. If your organization is a State
Medicaid Agency and would like to request flexibilities pursuant to section 1135 of the Social Security Act (Act), which
grants the Secretary of the United States Department of Health and Human Services authority to temporarily waive or
modify certain Medicare, Medicaid and Children’s Health Insurance Program (CHIP) requirements to ensure that
sufficient health care items and services are available to meet the needs of enrollees in an area affected by a federally
declared public health emergency (PHE), please complete the 1135 Medicaid & CHIP Checklist available at Section 1135
Waiver Flexibilities | Medicaid.
Once you have completed the checklist, please submit via email to: Medicaid 1135 [email protected] for CMS
review.
Please select all that apply
I want to submit a general waiver
I want to submit a Medicaid / CHIP waiver
Medicaid 1135 waivers for COVID-19 PHE cannot be submitted through this portal. Please see info box above.
Drop down options
PHE
Coronavirus Disease 2019 (COVID-19)
03/13/2020 - 07/16/2022
State/US Territory/Federal 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
Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.
What would you like to do?
Choose the applicable option below.
I want to submit a waiver / flexibility request 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.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those
impacted by an emergency or disaster.
I want to submit an inquiry request 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
You may use this option to report any impact on normal operations.
Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.
Provide Your Contact Information - Point of Contact
CMS uses your contact information to send responses and ask follow up questions.
Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.
Organization Information - State/US Territory/Federal District dropdown
Choose all applicable States, US Territories and/or Federal Districts where your healthcare facilities are located.
Provide Your Contact Information - Organization Categories
This provides CMS additional information on the type of organization requesting a waiver. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).
| File Type | application/pdf |
| File Modified | 2022-05-09 |
| File Created | 2022-05-06 |