Information Collection

Waiver Requests and Appeals

IC 278941 under ICR 202512-0925-004 · OMB 0925-0586.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Information Required for Waiver Requests and Appeals Waiver Requests and Appeals	Form and Instruction
Form 1 Information Required for Waiver Requests and Appeals Waiver Requests and Appeals	Form and Instruction
1 Information Required for Waiver Requests and Appeals Attachment 10 - Information Required for Waiver Request and Appeals 2_11_2026.pdf	Form and Instruction
1 Information Required for Waiver Requests and Appeals Attachment 10 - Information Required for Waiver Request and Appeals 2_11_2026.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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