Information Collection

Medicare Waiver Demonstration Application

IC 43670 under ICR 202505-0938-014 · OMB 0938-0880.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10069 Medicare Waiver Demonstration Application	Form and Instruction
Form CMS-10069 Medicare Waiver Demonstration Ajpplication 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
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
ruralcommunityhospitaldemo-rfa_12_20_24[79].pdf Rural Community Hospital Demo	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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-10069				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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
Rural Community Hospital Demo		06/02/2025

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].