1135 Waiver Request Automated Process

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10752 1135 Waiver Request Automated Process Form and Instruction
CMS-10752 Waiver Inquiry Form CMS 10752 NEW 1135 Waiver-Inquiry Collection Instrument (KY Flooding).pdf Form and Instruction
CMS-10752 Helath Care Facility Status Collection Form Health Care Facility Status Collection Instrument 2-9-21.pdf Form and Instruction
CMS 10752 Mock-Up of Previous 1135-Waiver-Inquiry Collection Instrument (KY Flooding).pdf Mock-up of Waiver Inquiry Form - KY Flooding IC Document
CMS 10752 1135 Waiver_Flexibility Request and 1135 Inquiry Form Revision Table - KY Flooding.pdf Crosswalk table of Waiver Inquiry Form - KY Flooding IC Document

Information Collection (IC) Details

IC Title:	1135 Waiver Request Automated Process	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10752	Waiver Inquiry Form	CMS 10752 NEW 1135 Waiver-Inquiry Collection Instrument (KY Flooding).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10752	Helath Care Facility Status Collection Form	Health Care Facility Status Collection Instrument 2-9-21.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,730	Number of Respondents for Small Entity: 300

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,730	3,730
Annual IC Time Burden (Hours)	3,730	3,730
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Mock-up of Waiver Inquiry Form - KY Flooding	CMS 10752 Mock-Up of Previous 1135-Waiver-Inquiry Collection Instrument (KY Flooding).pdf	08/03/2022
Crosswalk table of Waiver Inquiry Form - KY Flooding	CMS 10752 1135 Waiver_Flexibility Request and 1135 Inquiry Form Revision Table - KY Flooding.pdf	08/03/2022

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