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Federal forms, ICRs, and supporting documents

Information Collection

1135 Waiver Request Automated Process

IC 243968 under ICR 202209-0938-003 · OMB 0938-1384.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

1135 Waiver Request Automated Process
 
No Modified
 
Required to Obtain or Retain Benefits
 

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_Flexibility Request Collection Instrument (County Field)_Rev. Sept.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

Health Health Care Services

 

3,730 300
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,730 0 0 0 0 3,730
Annual IC Time Burden (Hours) 3,730 0 0 0 0 3,730
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track change - Waiver flexibility request CMS 10752 Mock-Up of Previous 1135-Waiver_Flexibility Request Collection Instrument (County Field)_Rev. Sept.pdf 09/12/2022
Crosswalk - Waiver Flexibility Request CMS 10752 1135 Waiver_Flexibility Request and 1135 Inquiry Form Revision Table - County Field_Rev. 090822.pdf 09/12/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.