1135 Waiver Request Automated Process

Submissions of 1135 Waiver Request Automated Process (CMS-10752)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1384 can be found here:

Documents and Forms

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

Information Collection (IC) Details

IC Title:	1135 Waiver Request Automated Process	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10752	Waiver Inquiry Form	CMS 10752 NEW_PRA 1135 Revision.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,699	Number of Respondents for Small Entity: 300

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,699	2,969	3,730
Annual IC Time Burden (Hours)	6,699	2,969	3,730
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track change - Waiver flexibility request	CMS 10752 Mock-Up_PRA 1135 Revision.pdf	08/09/2024
Crosswalk -1135 Web Portal (Health Care Facility portion)	CMS 10752 Crosswalk (HCF)_PRA Revision.pdf	05/28/2024

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