Information Collection

1135 Waiver Request Automated Process

IC 243968 under ICR 202208-0938-003 · OMB 0938-1384.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10752 1135 Waiver Request Automated Process	Form and Instruction
CMS-10752 Waiver Inquiry Form 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

IC Title:

1135 Waiver Request Automated Process

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10752	Waiver Inquiry Form	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 %

table that charts list of burden
	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

table that charts IC Documents
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.