New Instrument

8/12/23, 12:46 PM

CMS 1135 Waiver / Flexibility Request and Inquiry Form - CMS 1135 Form

CMS 1135 Waiver / Flexibility Request and Inquiry 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 would you like to do?



I want to submit a waiver / flexibility request 

I want to submit an inquiry request 

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



Select a Public Health Emergency

https://cmsqualitysupport.servicenowservices.com/cms_1135

1/2

8/12/23, 12:46 PM

CMS 1135 Waiver / Flexibility Request and Inquiry Form - CMS 1135 Form

Select the Public Health Emergency (PHE) that applies to your request



Public Health Emergency (PHE) (required)*

2024 Hurricane Debby XX/XX/XXXX - XX/XX/XXXX

CMS 1135 Waiver/Flexibility Request and Inquiry

A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 7500 Security Boulevard, Baltimore MD 21244

https://cmsqualitysupport.servicenowservices.com/cms_1135

2/2

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Adriane Saunders
File Modified	0000-00-00
File Created	2024-09-12