Medicare Waiver Demonstration Application

Medicare/Medicaid Demonstration/Model Application (CMS-10069)

Documents and Forms

Document Name Document Type
Form CMS-10069 Medicare Waiver Demonstration Application Form and Instruction
CMS-10069 Medicare Waiver Demonstration Ajpplication CMS-10069_Medicare_Demo_Waiver_App 12-6-16.pdf Form and Instruction
ruralcommunityhospitaldemo-rfa_12_20_24[79].pdf Rural Community Hospital Demo IC Document

Information Collection (IC) Details

IC Title:	Medicare Waiver Demonstration Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10069	Medicare Waiver Demonstration Ajpplication	CMS-10069_Medicare_Demo_Waiver_App 12-6-16.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	30	-45	75
Annual IC Time Burden (Hours)	2,400	-3,600	6,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Rural Community Hospital Demo	ruralcommunityhospitaldemo-rfa_12_20_24[79].pdf	06/02/2025

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