Information Collection

Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310

IC 8072 under ICR 202407-0938-020 · OMB 0938-0449.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-8003 Home & Community Based Waiver Requests and Supporting Regulations; 42 CFR 440.180, 441.300-.310	Form and Instruction
Instructions_TechnicalGuide_V3.7 CLEAN July 2024.pdf 3[1].pdf	Instruction
Instructions_TechnicalGuide_V3.7 CLEAN July 2024.pdf 3[1].pdf	Instruction
CMS-8003 Application for a Section 1915(c) Home and Community-Bas 1915(c) waiver template V3.7 July 2024 CLEAN[2].pdf	Form and Instruction
CMS-8003 Application for a Section 1915(c) Home and Community-Bas 1915(c) waiver template V3.7 July 2024 CLEAN[2].pdf	Form and Instruction
1915(c) waiver application V3.7 change crosswalk updated 2-20-24.pdf Crosswalk: Application	IC Document
1915(c) waiver application V3.7 change crosswalk updated 2-20-24.pdf Crosswalk: Application	IC Document
1915(c) waiver tech guide V3.7 change crosswalk 2023 updated 2-20-24.pdf Crosswalk: Technical Guide	IC Document
1915(c) waiver tech guide V3.7 change crosswalk 2023 updated 2-20-24.pdf Crosswalk: Technical Guide	IC Document
1915(c) waiver template V3.7 2024 MARK-UP 7-26-24.pdf Redline (Revised): Application	IC Document
1915(c) waiver template V3.7 2024 MARK-UP 7-26-24.pdf Redline (Revised): Application	IC Document
Instructions_TechnicalGuide_V3.7 MARK-UP 7-25-24[1].docx Redline (Revised): Technical Guide	IC Document
Instructions_TechnicalGuide_V3.7 MARK-UP 7-25-24[1].docx Redline (Revised): Technical Guide	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 440.180 42 CFR 441.300-310

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-8003	Application for a Section 1915(c) Home and Community-Based Services Waiver	1915(c) waiver template V3.7 July 2024 CLEAN[2].pdf		Yes	Yes	Fillable Fileable
Instruction			Instructions_TechnicalGuide_V3.7 CLEAN July 2024.pdf 3[1].pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	64	64
Annual IC Time Burden (Hours)	5,332	5,332
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Application	1915(c) waiver application V3.7 change crosswalk updated 2-20-24.pdf	03/19/2024
Crosswalk: Technical Guide	1915(c) waiver tech guide V3.7 change crosswalk 2023 updated 2-20-24.pdf	03/19/2024
Redline (Revised): Application	1915(c) waiver template V3.7 2024 MARK-UP 7-26-24.pdf	07/31/2024
Redline (Revised): Technical Guide	Instructions_TechnicalGuide_V3.7 MARK-UP 7-25-24[1].docx	07/31/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.