CMS-10834 EPCS Waiver Application

EPCS Waiver
Application
CMS

Opening Screen to Apply for a Waiver
EPCS Dashboard

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). This is a voluntary information collection.
The time required to complete this information collection is estimated to average 0.1667 hours per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact EPCS-EPrescribe@cms.hhs.gov.
Click here for Privacy Policies.

Enter Waiver Application Information
Submitter Details

•
•
•
•
•

Name
Email Address
Additional E-mail Addresses
Phone Number

Relationship to Prescriber

Waiver Details

• Reasons for Submitting a Waiver
•

Application
Documentation Upload to provide
existence of a circumstance
beyond control that prevented the
prescriber from conducting EPCS

Attestation Statement

• Reason(s) for Submitting a Waiver Application

0 Economic hardship prevents acquisition of system necessary to conduct EPCS
0 Technological limitations not within control of the prescriber (e.g. service area lacks broadband internet access. making ECPS
0

impractical. and/or software providers refuse to install necessary sysytem for conducting ECPS)
Other circumstance outside of prescriber's control

• Documentation proving existence of a circumstance beyond control that prevented the prescriber from conducting EPCS

Drop files to upload

I

or
Select Files

I

[.pdf•.jpg..jpeg ..png •.tiff.. doc•.dox. xis •. xlsx •.msg)
Maximum upload file size: 20 MB

Attestation

0

* I attest that:
On behalf of the Prescriber listed. or as the Prescriber in this attestation. I am applying for this EPCS Waiver and attest that
the Prescriber is unable to conduct Electronic Prescribing for Controlled Substances (EPCS) due to circumstances beyond the
Prescriber's control.

Collection of information in this form is covered by 0MB-10834 - please see the EPCS Privacy Page 0 for more details.

✓ All changes saved

Save &Close

Submit Application

Certify and Submit

• Review previously submitted details and general notice
• Select “Certify & Submit” button
X

Certify & Submit

O

By submitting this EPCS Waiver Application. I am certifying that the details entered are correct to the best of my
knowledge. Furthermore. I am submitting this waiver application as if I physically signed and submitted a hard copy of
this form.

Submission Summary
Prescriber Details

NPI

Prescriber Name

Prescriber Type

Mailing Address

1000000111

Test Prescriber 11

Family Medicine

123 Testing St Suite 11
Mechanicsville, PA 123451234

Su bmitter Deta ils
Name

Email Address

Natalia1 Furman

natalia1.sviriduk@semanticbits.com (301) 515-0239

Relationship to Prescriber

Additional Email Address(es)

Consultant

• nsviriduk@yahoo.com

Phone Number

Waiver Detai ls
Reason(s) for Submitting Waiver Application

• Economic hardship prevents acquisition of system necessary to conduct EPCS

General Notice
No Electronic Prescribing for Controlled Substances (EPCS) Waiver may be granted unless this application is
completed.
Disclosures
Submission of this EPCS Waiver Application is voluntary. Failure to provide necessary information to identify
the prescriber will result in processing delays or denial of the EPCS Waiver Application.
Notice
Any person who knowingly files a statement of claim containing any misrepresentation or any false.
incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject
to civil penalties.

Cancel

Certify & Submit

General Notice Text
The image on this slide captures the complete text included in the general notice box.

General Notice Text

EPCS Waiver Application Submitted
Upon completion of these steps, the site confirms the successful submission of the EPCS
waiver application