Form CMS-10752 Acute Hospital at Home

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

Acute Hospital Care at Home Screenshots

Acute Hospital Care at Home

OMB: 0938-1384

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1384 can be found here:

2025-01-10 - No material or nonsubstantive change to a currently approved collection
2024-10-08 - No material or nonsubstantive change to a currently approved collection

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When a hospital submits a waiver request, it completes one of two online forms found on the waiver landing page (https://qualitynet.cms.gov/acute-hospital-care-at-home), depending on its level of experience with this type of care. Experienced hospitals, defined as treating at least 25 patients with acute hospital care at home previously, have an expedited submission that is based on a series of attestations, seen below:

Less experienced hospitals, defined as treating fewer than 25 patients with this level of care previously, complete a more detailed waiver request, seen below:

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Author	Jill Newsam
File Modified	0000-00-00
File Created	2022-09-14