1135 Waiver Request Automated Process

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

OMB: 0938-1384

IC ID: 243968

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_PRA 1135 Revision.pdf Yes Yes Fillable Fileable

Health Health Care Services


6,699 300
Private Sector Businesses or other for-profits, Not-for-profit institutions
   100 %

  Requested 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 6,699 0 2,969 0 0 3,730
Annual IC Time Burden (Hours) 6,699 0 2,969 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_PRA 1135 Revision.pdf 05/28/2024
Crosswalk -1135 Web Portal (Health Care Facility portion) CMS 10752 Crosswalk (HCF)_PRA Revision.pdf 05/28/2024
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