CMS 1135 Waiver/ Flexibility Request and Inquiry Web Portal Form

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CMS 1135 Wa ive r / Fle xib ilit y Re q u e s t a n d In q u ir y We b Po r t a l Fo r m

He alth Care Facility Status

CMS 1135 Wa ive r / Fle xib ilit y Re q u e s t a n d In q u ir y We b Po r t a l Fo r m
Acco rd ing to th e Pa pe rwo rk Re du ctio n Act of 1995, n o p e rso ns a re re q u ire d to re spo n d to a co lle ctio n o f info rm a tio n u n le ss it d ispla ys a va lid
OMB co ntrol n u m b e r. The va lid OMB co ntrol n u m b e r fo r th is in fo rm a tio n colle ctio n is 0938-1384 (Exp ir e s 08/ 31/ 2026). Th is is a vo lu n t a r y
in fo rm atio n co lle ctio n . Th e tim e re q u ire d to co m p le te th is info rm a tio n co lle ction is e stim a te d to a ve ra ge 1 h o u r p e r re sp o nse , in clu d in g the tim e
to re vie w in stru ctio n s, se a rch e xistin g d ata re sou rce s, gath e r the d a ta n e e d e d , a n d co m p le te a n d re vie w the in fo rm a tio n colle ctio n. If yo u h a ve
co m m e n ts co n ce rn in g th e a ccu ra cy o f th e tim e e stim ate (s) o r sugge stio n s fo r im p roving th is fo rm , p le a se write to : CMS, 7500 Se cu rity Bo ule va rd ,
Attn : PRA Re p o rts Cle a ra n ce Office r, Ma il Sto p C4-26-05, Ba ltim o re , Ma ryla n d 21244-1850. ****CMS Dis clo s u r e **** Ple a se d o n o t s e n d
a p p lica t io n s , cla im s , p a ym e n t s , m e d ica l r e co r d s o r a n y d o cu m e n t s co n t a in in g s e n s it ive in fo r m a t io n t o t h e PRA Re p o r t s Cle a r a n ce
Office . Ple a se n o t e t h a t a n y co r r e s p o n d e n ce n o t p e r t a in in g t o t h e in fo r m a t io n co lle ct io n b u r d e n a p p r o ve d u n d e r t h e a s s o cia t e d OMB
co n t r o l n u m b e r lis t e d o n t h is fo r m w ill n o t b e r e vie w e d , fo r w a r d e d , o r r e t a in e d . If yo u h a ve q u e s t io n s o r co n ce r n s r e ga r d in g w h e r e t o
s u b m it yo u r d o cu m e n t s , p le a se co n t a ct Ad r ia n e Sa u n d e r s a t Ad r ia n e .Sa u n d e r s @cm s .h h s .go v.
So m e tim e s the n o rm a l o p e ration s o f a h e a lth ca re p ro vide r a re disru p te d b y e m e rge n cie s o r d isaste rs. Ple ase do cu m e n t the cu rre n t statu s o f
yo u r o rga n iza tio n in clu din g im p act to b e ne ficia rie s.

Stakeholders now have the
flexibility to submit status
updates during any emergency

Added a dedicated field to
record the specific date on
which the emergency event
took place.

Expanded the cybersecurity
section that enable
stakeholders to report the
extent of negative impacts
from cyberattacks on both
patients and operational
functions (These fields
appear when the
Cybersecurity box is
checked).

Drop down options

Cybersecurity
Ambulance Diversion
Multiple
OB/Labor & Delivery

STEMI
Internal Disaster

Trauma
ED Saturation

Stroke
Other

Ancillary Services
Multiple
Beh. & Mental Health
Diabetes Education
Med Spa
Occupational Therapy
Sleep Laboratory Svcs
Wound Care

ALL
Blood Test
Genetic Testing
Medical Day Care
Pharmacy Services
Speech Therapy
Other

Allergy Services
Audiology
Cardiac Monitoring
Care Delivery Services
Home Infusion Care
Laboratory Tests
Mobile Diagnostic Svcs
Nutrition and Food Svcs
Physical Therapy
Private Duty Nursing
Telemedicine
Respiratory/Ventilator Svcs
Radiology/Ventilator Svcs