Form CMS-10752 Waiver Inquiry Form

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].

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 request

?

I want to submit an inquiry request

?

?

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

Kentucky Flooding

7/26/2022 - 10/24/2022

New Mexico Straight Line Winds and
Wildfire

04/05/2022 - 10/02/2022

Coronavirus Disease 2019 (COVID-19)

03/13/2020 - 10/14/2022

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

First name

(required) *

Last name

(required) *

(required) *

Phone number
(XXX)XXX-XXXX

Organization Information

?

Who is the organization making this request?

Organization name

(required) *

State/US Territory/Federal District (required) *

?

Nebras
NebraNebra
skaksaka
Nevada

New York

Organization Categories

?

Who is the organization making this request?

General

Emergency Provider / Supplier Types

Other

Advocacy Groupurable Medical
Equipment (DME)
Association

State Government

Corporation

State Medicaid or CHIP Agency

Medicare Advantage / Part D Plan

State Survey Agency

General

Tribal Nation

Qualified Health Plan

Emergency Provider / Supplier Types

Other

Ambulatory Surgical Center (ASC)

Nursing Homes (SNF/NF)

Community Mental Health Center

(CMHC)

Organ Procurement Organization (OPO)

Comprehensive Outpatient

Rehabilitation Facility (CORF)

Outpatient Physical Therapy/Speech

Therapy (OPT/ST)

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:

NAME-OF-IDENTIFICATION-NUMBER
Separate multiple identification numbers with a comma.

3

Describe your 1135 Waiver / Flexibility Request

?

Select the type of request you are making. Depending on your request type, we may ask
you for additional information.

Request #1
Waiver Request Type

(required) *

Training and Certification of Nurse Aides
Click here if you do not see your Waiver Request Type
Please select a State/US Territory/Federal District (required) * ?

New Mexico
Please select a County (required) *

Bernalillo

?

Catron

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.

+

4

Add another waiver request

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
Kentucky Flooding 07/26/2022 - 10/24/2022
New Mexico Straight Line Winds and Wildfire 04/05/2022 - 10/02/2022
Coronavirus Disease 2019 (COVID-19) 03/13/2020 - 10/14/2022

State/US Territory/Federal District

Alabama

Alaska

American Samoa

Arizona

Arkansas

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

Accreditation Organizations: Survey, Certification, Quality and Enforcement

Ambulatory Surgery Center (ASC): Survey, Certification, Quality and Enforcement

Ambulatory Surgical Center (ASC): Payment

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

Certified Nursing Assistants: Survey, Certification, Quality and Enforcement

Clinical Laboratory Improvement Amendments (CLIA): Survey, Certification, Quality and Enforcement

Community Health Center (CHC): Payment

Community Mental Health Center (CMHC): Payment

Comprehensive Outpatient Rehabilitation facilities (CORF): Payment

Comprehensive Outpatient Rehabilitation facilities (CORF): Survey, Certification, Quality and Enforcement

Conditions of Participation (COP)

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: 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

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

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

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: Survey, Certification, Quality and Enforcement

Hospice: Payment

Hospice: Survey, Certification, Quality and Enforcement

Hospital Inpatient: Payment

Hospital Outpatient: Payment

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)

Inpatient Rehab Facility (IRF): Survey, Certification, Quality and Enforcement

Inpatient Rehab Facility (IRF): Payment

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID): Survey, Certification, Quality and

Enforcement

Intermediate Care Facility (ICF): Payment

Lab: Payment

Life Safety Code (LSC)

Minimum Data Set (MDS): Payment

Minimum Data Set (MDS): Survey, Certification, Quality and Enforcement

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

Portable X-Ray: Payment

Portable X-Ray: Survey, Certification, Quality and Enforcement

Preadmission Screen and Resident Review (PASARR): Survey, Certification, Quality and Enforcement

Psychiatric Residential Treatment Facility (PRTF): Survey, Certification, Quality and Enforcement

Quality

Religious Nonmedical Health Care Institution Coverage (RNHCI): Payment

Religious Nonmedical Health Care Institution Coverage (RNHCI): Survey, Certification, Quality and Enforcement

Replacement Prescription Fills: Permit Medicare payment for replacement prescription fills (for a quantity up to the

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

Transplant: Payment

Transplant: Survey, Certification, Quality and Enforcement

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).
Please select a State/US Territory/Federal District

[add new content here]
Please select a county

[add new content here]