Track change - Waiver flexibility request

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

CMS 1135 General Waiver Request

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form
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 0938-1384 (Expires 05/31/2024). This is a voluntary
information collection. The time required to complete this information collection is estimated to average 1 hour 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 Adriane Saunders at Adriane.Saunders@cms.hhs.gov.
If you have a request or inquiry, please use this form to submit your request to CMS.

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a disaster or emergency. Blanket
waivers prevent gaps in the access to care for beneficiaries affected by the emergency.
When a blanket waiver is issued, providers do not have to apply for an individual waiver. If there is no blanket waiver, providers can ask for an
individual Section 1135 waiver.

Submit a waiver / flexibility request

What are the identification numbers for your organization?
Please include all applicable identification numbers for the healthcare facilities/providers affiliated with your organization impacted by the PHE.
These numbers will be different depending on the categories you have selected for your organization, including: CCN/Provider, Medicare
Contract Number, or NPI.

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

CMS 1135 Inquiry Request

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form
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 0938-1384 (Expires 05/31/2024). This is a voluntary
information collection. The time required to complete this information collection is estimated to average 1 hour 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 Adriane Saunders at Adriane.Saunders@cms.hhs.gov.
If you have a request or inquiry, please use this form to submit your request to CMS.

What are the identification numbers for your organization?
Please include all applicable identification numbers for the healthcare facilities/providers affiliated with your organization impacted by the PHE.
These numbers will be different depending on the categories you have selected for your organization, including: CCN/Provider, Medicare
Contract Number, or NPI.

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

CMS 1135 Medicaid/CHIP Waiver Request
Standard Waiver

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

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 0938-1384 (Expires 05/31/2024). This is a voluntary
information collection. The time required to complete this information collection is estimated to average 1 hour 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 Adriane Saunders at Adriane.Saunders@cms.hhs.gov.
If you have a request or inquiry, please use this form to submit your request to CMS.

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a disaster or emergency. Blanket
waivers prevent gaps in the access to care for beneficiaries affected by the emergency.
When a blanket waiver is issued, providers do not have to apply for an individual waiver. If there is no blanket waiver, providers can ask for an
individual Section 1135 waiver.

Submit a waiver / flexibility request

What are the identification numbers for your organization?
Please include all applicable identification numbers for the healthcare facilities/providers affiliated with your organization impacted by the PHE.
These numbers will be different depending on the categories you have selected for your organization, including: CCN/Provider, Medicare
Contract Number, or NPI.

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

CMS 1135 Medicaid/CHIP Waiver Request
Standard Waiver with Additional Information

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

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 0938-1384 (Expires 05/31/2024). This is a voluntary
information collection. The time required to complete this information collection is estimated to average 1 hour 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 Adriane Saunders at Adriane.Saunders@cms.hhs.gov.
If you have a request or inquiry, please use this form to submit your request to CMS.

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a disaster or emergency. Blanket
waivers prevent gaps in the access to care for beneficiaries affected by the emergency.
When a blanket waiver is issued, providers do not have to apply for an individual waiver. If there is no blanket waiver, providers can ask for an
individual Section 1135 waiver.

Submit a waiver / flexibility request

What are the identification numbers for your organization?
Please include all applicable identification numbers for the healthcare facilities/providers affiliated with your organization impacted by the PHE.
These numbers will be different depending on the categories you have selected for your organization, including: CCN/Provider, Medicare
Contract Number, or NPI.

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

CMS 1135 Medicaid/CHIP Waiver Request
Other Waiver with Applicable Regulation

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

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 0938-1384 (Expires 05/31/2024). This is a voluntary
information collection. The time required to complete this information collection is estimated to average 1 hour 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 Adriane Saunders at Adriane.Saunders@cms.hhs.gov.
If you have a request or inquiry, please use this form to submit your request to CMS.

Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a disaster or emergency. Blanket
waivers prevent gaps in the access to care for beneficiaries affected by the emergency.
When a blanket waiver is issued, providers do not have to apply for an individual waiver. If there is no blanket waiver, providers can ask for an
individual Section 1135 waiver.

Submit a waiver / flexibility request

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form

Health Care Facility Status

CMS 1135 Waiver / Flexibility Request and Inquiry Web Portal Form
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 0938-1384 (Expires 05/31/2024). This is a voluntary
information collection. The time required to complete this information collection is estimated to average 1 hour 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 Adriane Saunders at Adriane.Saunders@cms.hhs.gov.
Sometimes the normal operations of a healthcare provider are disrupted by emergencies or disasters. Please document the current status of
your organization including impact to beneficiaries.

Removed the PHE dropdown from Section 1

Moved CMS CCN to be the first
item in Section 2 so that the blue
shaded fields are auto-populated if
a valid CCN is provided

Added a check box just in case
the health care facility doesn’t see
their organization category

Added the ‘Do you have
sufficient staffing?’ section

Changed the ‘Census’ section to a REQUIRED field
Drilled
down
further of
where
patients
and
residents
are
evacuated
This field auto-calculates based on
information entered in the above fields

Added this field to capture the number of
patients/residents repatriated

Added
‘Supply/Equipment
Concerns’ to the
“Other Impacts to
Facility” section

Added the ‘Details
of the Health Care
Facility Status’
section to the form

Drop down options