Information Collection

1135 Waiver Request Automated Process

IC 243968 under ICR 202606-0938-015 · OMB 0938-1384.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10752 Waiver Inquiry Form 1135 Waiver Request Automated Process	Form and Instruction
CMS-10752 Waiver Inquiry Form CMS 10752 HCF NEW_PRA 1135 Revision.pdf	Form and Instruction
CMS 10752 HCF Mock-Up_PRA 1135 Revision.pdf Track change - Waiver flexibility request	IC Document
CMS 10752 Crosswalk (HCF)_PRA Revision.pdf Crosswalk -1135 Web Portal (Health Care Facility portion)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10752				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,829

Number of Respondents for Small Entity: 300

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,829	-1,870	6,699
Annual IC Time Burden (Hours)	4,016	-2,683	6,699
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track change - Waiver flexibility request		06/18/2026
Crosswalk -1135 Web Portal (Health Care Facility portion)		06/18/2026

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

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