Form CMS-10752 Waiver Inquiry Form

The COVID-19 PHE is Ending on [xx]
Throughout the COVID-19 public health emergency (PHE), CMS has used a combination of
emergency authority waivers, regulations, enforcement discretion, and sub-regulatory
guidance to ensure access to care and give health care providers the flexibilities needed to
respond to COVID-19 and help keep people safer. Many of these waivers and broad
flexibilities will terminate at the eventual end of the PHE, as they were intended to address
the acute and extraordinary circumstances of a rapidly evolving pandemic and not replace
existing requirements. To minimize any disruptions, including potential coverage losses,
following the end of the PHE, HHS Secretary Becerra committed to giving states and the
health care community writ large 60 days' notice before ending the PHE. He issued that notice
on XXX. CMS will continue to accept waiver requests until XXX when the COVID-19 PHE
officially ends.

Fact Sheets by provider type

CMS has encouraged health care providers to prepare for the end of these flexibilities as
soon as possible and to begin reestablishing previous health and safety standards and billing
practices. Click the button to the right to access our fact sheets that outline which blanket
waivers and flexibilities will terminate at the end of the PHE, by provider type.

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].
If you have a request or inquiry, please use this form to submit your request to CMS.

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

?

?

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers

when there's a disaster or emergency. Blanket waivers prevent gaps in the access to care for

beneficiaries affected by the emergency.

When a blanket waiver is issued, providers don't have to apply for an individual waiver. If there's no

blanket waiver, providers can ask for an individual Section 1135 waiver.

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

1135 Waiver Request when No PHE declared

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 Group

Medicare Advantage Plan

Association

Part D Prescription Plan

Congressional Office

State Government

Corporation

State Medicaid or CHIP Agency

Department of Health and Human
Services

State Survey Agency

General

Emergency Provider / Supplier Types

Tribal Nation

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) *

?

Regulation Related to this Request

Request Description

(required) *

?

?

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.

Detail

+

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

1135 Waiver Request when No PHE declared
State/US Territory/Federal District

Alabama

Alaska

American Samoa

Arizona

Arkansas

Armed Forces America

Armed Forces Europe

Armed Forces Pacific

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

Conditions of Participation (COP)

Payment

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).

The COVID-19 PHE is Ending on [xx]
Throughout the COVID-19 public health emergency (PHE), CMS has used a combination of
emergency authority waivers, regulations, enforcement discretion, and sub-regulatory
guidance to ensure access to care and give health care providers the flexibilities needed to
respond to COVID-19 and help keep people safer. Many of these waivers and broad
flexibilities will terminate at the eventual end of the PHE, as they were intended to address
the acute and extraordinary circumstances of a rapidly evolving pandemic and not replace
existing requirements. To minimize any disruptions, including potential coverage losses,
following the end of the PHE, HHS Secretary Becerra committed to giving states and the
health care community writ large 60 days' notice before ending the PHE. He issued that notice
on XXX. CMS will continue to accept waiver requests until XXX when the COVID-19 PHE
officially ends.

Fact Sheets by provider type

CMS has encouraged health care providers to prepare for the end of these flexibilities as
soon as possible and to begin reestablishing previous health and safety standards and billing
practices. Click the button to the right to access our fact sheets that outline which blanket
waivers and flexibilities will terminate at the end of the PHE, by provider type.

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].
If you have a request or inquiry, please use this form to submit your request to CMS.

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

?

?

Submit an inquiry
1 Select a Public Health Emergency
Select the Public Health Emergency (PHE) that applies to your inquiry request

Public Health Emergency (PHE) (required) * ?
Please select one
Coronavirus Disease 2019 (COVID-19)

03/13/2020 - 05/11/2023

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 inquiry request?

Email address (required) *

Confirm email address (required) *

First name (required) *

Last name (required) *

Zip code (required) * ?
XXXXX

Phone number
(XXX)XXX-XXXX

Organization Information ?
Who is the organization making this request?

Organization name (required) *

Organization Categories ?
Who is the organization making this request?

General

Emergency Provider / Supplier Types

Other
Tribal Nation

Advocacy Group

Medicare Advantage Plan

Association

Part D Prescription Plan

Congressional Office

State Government

Corporation

State Medicaid or CHIP Agency

Department of Health and
Human Services

General

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
Intermediate Care Facility for Individuals
with
Intellectual Disabilities (ICF/IID)

General

Emergency Provider / Supplier Types

Ambulance

Palliative

Durable Medical Equipment (DME)

Physician

ab

Other

L

Transplant Center

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:

?

IDENTIFICATION NUMBER

Separate multiple identification numbers with a comma.

3

Inquiry
Request #1
Topic (required) *

?

Type (required) *

?

Click here if you do not see your type

Description (required) *

?

Provide a comprehensive description of your inquiry (including regulation citations if applicable).

+

4

Add another inquiry request

Submit your inquiry
Submit

Thank You! Your inquiry has been successfully submitted.

Y

our case number is

ou will also receive an email confirmation summarizing your request and providing you with additional

guidance.

Y

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
Coronavirus Disease 2019 (COVID-19)

03/13/2020 - 05/11/2023

Topic

Medicaid / CHIP

Medicare Advantage / Prescription Drug Plan

Original Medicare (Part A or B)

Qualified Health Plans

Type

638 Tribal Clinics

Academia

Access to Care

Advocate

Ambulance

Ambulatory Care Center

Appeals

Association / Society for Provider / Facility

Attorney for Provider / Facility

Appendix K

Billing Agency

Consultant for Provider / Facility

Critical Access Hospital

Denials

Dialysis Facility

Eligibility

Employer

End of COVID-19 PHE: 1135 Waiver Question

Facility

Federal / State Government Agency

Fair Hearings

Federally Qualified Health Center (FQHC)

General Public

HCBS Waivers

Home Health

Hospice

Hospital

Insurance Company

Long Term Care Services and Supports

Managed Care

Medical Supplier/DME

Nurse / Nurse Practitioner

Nursing Home

Payment Methodology / Rates

Pharmacist / Pharmacy

Physical / Occupational Therapy

Physician

Physician Assistant

Provider Enrollment

Provider - Mental Health

Provider - Other

Respite

Retainer Payments

Rural Health Clinic (RHC)

Skilled Nursing Facility

State Agency

Telehealth

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.

Zip code

Please enter your 5 digit zip code.

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.

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.

Topic

Choose from the dropdown list which category your inquiry would fall under.

Type

Choose your inquiry type from the drop down list.