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Federal forms, ICRs, and supporting documents

Information Collection

1135 Waiver Request Automated Process

IC 243968 under ICR 202409-0938-027 · OMB 0938-1384.

Documents and Forms
Document Name
Document Type
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 Unchanged
 
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 Not-for-profit institutions, Businesses or other for-profits
 
   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 6,699 0 0 0 0 6,699
Annual IC Time Burden (Hours) 6,699 0 0 0 0 6,699
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 08/09/2024
Crosswalk -1135 Web Portal (Health Care Facility portion) CMS 10752 Crosswalk (HCF)_PRA Revision.pdf 05/28/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.