Information Collection

Waiver Requests (POs)

IC 223824 under ICR 202411-0938-003 · OMB 0938-1326.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10631 Waiver Requests (POs)	Form and Instruction
CMS-10631 PACE Application PACE Application_clean_062024.docx	Form and Instruction
CMS-10631 PACE Application PACE Application_clean_062024.docx	Form and Instruction
PACE Application combined review__redline_062024.docx PACE Application combined review__redline	IC Document
PACE Application combined review__redline_062024.docx PACE Application combined review__redline	IC Document

IC Title:

Agency IC Tracking Number:

CM-CPC

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.26

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-10631	PACE Application	PACE Application_clean_062024.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PACE Application combined review__redline	PACE Application combined review__redline_062024.docx	11/08/2024

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