Form CMS-10752 Waiver Inquiry Form

CMS 1135 Waiver / Flexibility Request and Inquiry Form

Organization Workflow
CMS 1135 Waiver / Flexibility Request

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 02/28/2021). 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.

Who are you?

?

An Organization / Provider
A Beneficiary

What would you like to do?

?

I want to submit a waiver / flexibility request

I want to submit an inquiry

?

?

I want to provide a status update on my beneficiaries and/or healthcare facility

?

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 don't have to apply for an individual waiver. If there's no
blanket waiver, providers can ask for an individual Section 1135 waiver.

Submit a waiver / flexibility request
1 Select a Public Health Emergency

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

?

Public Health Emergency (PHE) (required) *
Please select one
COVID-19

01/27/2020 - 04/20/2021
08/13/2020 - 10/31/2021

California Wildfire

CA

2 Provide Your Contact Information

This will help keep you updated on your request’s progress

Point of Contact

?

Who should CMS contact in response to this waiver request?

Email address

(required) *

Confirm email address

(required) *

First name (required) *

Last name (required) *

Phone number
(XXX)XXX-XXXX

Organization Information ?
Who is the organization making this request?

Organization Name (required) *

State/US Territory/Federal District (required) *

?

Nebraska
NebraNebraskaska

Nevada

New York

Organization Categories

(required) *

?

Who is the organization making this request?

Emergency Provider / Supplier Types

General

Other

Association

State Government

Advocacy Group

State Survey Agency

Corporation

Tribal Nation

Emergency Provider / Supplier Types

General

Other

Ambulatory Surgical Center (ASC)

Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)

Community Mental Health Center
(CMHC)

Nursing Homes (SNF/NF)

Comprehensive Outpatient
Rehabilitation Facility (CORF)

Organ Procurement Organization (OPO)

Critical Access Hospital (CAH)

Outpatient Physical Therapy/Speech
Therapy (OPT/ST)

Community Mental Health Center
(CMHC)

Psychiatric Residential Treatment
Facility (PRTF)

End Stage Renal Disease (ESRD)

Religious Non-Medical Health Care
Institution (RNCHI)

Home Health Agencies (HHA)

Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)

Hospice

Transplant Center

Hospital

Emergency Provider / Supplier Types

General

Ambulance

Palliative

Durable Medical Equipment (DME)

Physician

Lab

Other

Organization Identification Numbers

Other

Other Organization Category

?

What are the identification numbers for your organization?
These numbers will be different, depending on the categories you have
selected for your organization including: CCN/Provider, Medicare Contract
Number, or NPI.
For the categories selected above, use:

IDENTIFICATION NUMBER
Separate multiple identification numbers with a comma.

3 Describe your 1135 Waiver / Flexibility Request

Request #1
Waiver Request Type (required) *

?

Click here if you do not see your Waiver Request Type

Regulation Related to this Request

?

Request Description

?

(required) *

Detail a brief summary of why the waiver is needed (For example: CAH is sole community provider
without reasonable transfer options at this point during the specified emergent event (e.g. flooding, tornado,
fires, or flu outbreak). CAH needs a waiver to exceed its bed limit by X number of beds for Y days/weeks (be
specific)) and the type of relief you are seeking.

+ Add another waiver request

4 Submit your request

Submit

Thank You! Your request has been successfully submitted.
Your case number is 
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.

WARNING: Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the
Privacy Act of 1974. Submission to the 1135 Waivers System that contains Protected Health Information (PHI) is a violation of these Acts. Questions
containing PHI will be deleted from the system and not processed. For detailed information regarding safeguarding protected healthcare information or
data, please refer to the "HIPAA Security Rule" (https://www.hhs.gov/hipaa/for-professionals/index.html).

INFORMATION NOT TO BE RELEASED TO PUBLIC UNLESS AUTHORIZED BY LAW: This information is for internal Government use only and has not been
publicly disclosed. It may contain information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share
Publicly Identifiable Information (PII) and/or Public Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of the
law.

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

Drop down options
PHE
COVID-19

01/27/2020 - 04/20/2021

California Wildfire

08/13/2020 - 10/31/2020 CA

State/US Territory/Federal District
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces America
Armed Forces Europe
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
US Virgin islands
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming

Waiver/Flexibility Request Type
Accelerated Advanced Payment
Accreditation Organizations: Survey, Certification, Quality and Enforcement
Acute Care Hospital (ACH) Patient in Excluded Distinct Part Units
Acute Care Hospitals (ACH) with Distinct Part Inpatient Psychiatric Units
Allow individual’s representative to render 1915(j) services
Allow individual’s representative to render 1915(k) services
Allowing legally responsible individuals to render personal care services
Allow Private Duty Nursing (PDN) services to be delivered by a graduate registered nurse and/or a graduate licensed
practical nurse
Alternate Treatment Sites
Ambulance
Ambulatory Surgery Center (ASC): Survey, Certification, Quality and Enforcement
Ambulatory Surgical Center (ASC): Payment
Annual Wellness Visit (AWV)
Bankruptcy
Beneficiaries Notices & Signature Requirements
Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital: Allows IPPS and other acute care
hospitals that need to relocate inpatients from psychiatric unit to an acute care bed and unit
Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital: Allows IPPS and other acute care
hospitals that need to relocate inpatients from rehabilitation unit to an acute care bed and unit
Certification
Certified Nursing Assistants: Survey, Certification, Quality and Enforcement
Clinical Laboratory Improvement Amendments (CLIA): Survey, Certification, Quality and Enforcement
Community Health Center (CHC): Payment
Community Mental Health Center (CHC): Payment
Community Mental Health Center (CHC): Survey, Certification, Quality and Enforcement
Comprehensive Outpatient Rehabilitation facilities (CORF): Payment
Comprehensive Outpatient Rehabilitation facilities (CORF): Survey, Certification, Quality and Enforcement
Conditions of Participation (COP)
Cost Reports
Critical Access Hospital (CAH): Survey, Certification, Quality and Enforcement
Critical Access Hospital (CAH): Waive the requirements that limit the number of beds to 25 and the length of stay to 96
hours
Critical Access Hospital (CAH): Payment
Diabetes Self-Management: Payment
Diabetes Self-Management: Survey, Certification, Quality and Enforcement
Durable Medical Equipment (DME): If lost, destroyed, irreparably damaged or otherwise rendered unusable, waive
requirements such that face-to-face requirements, a new physician’s order and new medical necessity doc
Eligible Practitioners
Emergency Preparedness
EMTALA: Payment
EMTALA: Survey, Certification, Quality and Enforcement
End Stage Renal Disease (ESRD): Payment
End Stage Renal Disease (ESRD): Survey, Certification, Quality and Enforcement
Ensuring Correct Processing of Home Health Disaster related Claims: Allow MACs to extend auto-cancellation date of
Requests for Anticipated Payment (RAPs) during emergencies
Evaluation and Management: Payment
Exhaustion of Part A Benefits
Extended Repayment Schedule for Overpayments
Extension for Inpatient Prospective Payment System (IPPS) Wage Index Revisions
Extension for Inpatient Prospective Payment System (IPPS) Wage Index Revisions: Allows Hospital Wage Index development
Time Table for hospitals to request revisions
Extension for medicare Geographic Classification Review Board (MGCRB) Applications: Allows an extension to the deadline
of application re-classification requirements
Extension of pre-exisiting fee-for-service prior authorizations
Extension of timeframe for reinstatement of services and benefits for a fair hearing request after the date of the action
Extension of timelines for state fair hearing requests and appeals
Federally Qualified Health Center (FQHC): Payment
Federally Qualified Health Center (FQHC): Survey, Certification, Quality and Enforcement
Home Health Agency (HHA): Timeframe for OASIS transmission
Home Health Agency (HHA): Payment
Home Health Agency (HHA): Survey, Certification, Quality and Enforcement
Home Infusion Therapy: Payment
Home Infusion Therapy: Survey, Certification, Quality and Enforcement
Hospice: Payment
Hospice: Survey, Certification, Quality and Enforcement
Hospital Inpatient: Payment
Hospital Outpatient: Payment
Hospital: Survey, Certification, Quality and Enforcement
Housing Acute Care Patients in Excluded Distinct Part Units: Allows the authority to house acute care inpatients in excluded
distinct part units (where appropriate)
Inpatient Rehab Facility (IRF): Survey, Certification, Quality and Enforcement
Inpatient Rehab Facility (IRF): Payment
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID): Survey, Certification, Quality and
Enforcement
Intermediate Care Facility (ICF): Payment
Lab: Payment
Level of Care Requirement
Life Safety Code (LSC)
Long Term Care Hospital (LTCH) Benefit Requirements
Medicare Provider Locations (Billing)
Medicare Telehealth
Minimum Data Set (MDS): Payment
Minimum Data Set (MDS): Survey, Certification, Quality and Enforcement
Modification of deadline for a face-to-face encounter for 1905(a)(7) home health state plan services
Modification of deadline for annual review of the service plan required for the 1915(j) state plan benefit
Modification of deadline for conducting annual monitoring and follow up activities for targeted case management
Modification of deadline for conducting initial assessments for 1915(j) self-directed Personal Assistance Services
Modification of deadline for initial evaluations of eligibility and assessments of functional needs for 1915(i) state plan
benefits
Modification of deadline for initial level of care determinations for 1915(c) HCBS waivers
Modification of deadline for initial level of care determinations for 1915(k) state plan benefits
Modification of deadline for level of care redeterminations for 1915(c) HCBS waivers
Modification of deadline for initial level of care determinations for 1915(k) state plan benefits and 1915(c) HCBS waivers
Modification of deadline for re-evaluations of eligibility and reassessments of functional needs for 1915(i) state plan
benefits
Modification of deadline for reassessments of functional need for 1915(k) state plan benefits
Nursing Homes (SNF/NF): Survey, Certification, Quality and Enforcement
OASIS: Payment
OASIS: Survey, Certification, Quality and Enforcement
Organ Procurement Organizations: Survey, Certification, Quality and Enforcement
Outpatient Physical Therapy/Outpatient Speech Pathology: Payment
Outpatient Physical Therapy/Outpatient Speech Pathology: Survey, Certification, Quality and Enforcement
Part A or B Appeals
Part A or B Claims Processing
Part A or B Authorizations
Part A or B Provider Audits
Part A or B Provider Licensure Requirements
Part A or B Provider Locations (Billing)
Part A or B Provider: Payment
Part B Drug Coverage
Part B Drug Payment
Part B Outpatient Claims
Part B Outpatient: Payment
Permit state and clinic to temporarily designate a clinic practioner’s location as part of the clinic facility so that clinic
services may be provided via telehealth
Portable X-Ray: Payment
Portable X-Ray: Survey, Certification, Quality and Enforcement
Preadmission Screen and Resident Review (PASARR): Survey, Certification, Quality and Enforcement
Provider Enrollment Requirements
Provision of clinic services within scope without supervision of physician or dentist
Psychiatric Residential Teatment Facility (PRTF): Payment
Psychiatric Residential Teatment Facility (PRTF): Survey, Certification, Quality and Enforcement
Religious Nonmedical Health Care Institution Coverage (RNHCI): Payment
Religious Nonmedical Health Care Institution Coverage (RNHCI): Survey, Certification, Quality and Enforcement
Rural Health Clinic: Payment
Rural Health Clinic: Survey, Certification, Quality and Enforcement
Safety
Skilled Nursing Facility (SNF): 3-day Prior Hospitalization
Skilled Nursing Facility (SNF): For beneficiaries who exhausted their SNF benefits, renewed SNF coverage without first
having to start a new benefit period
Skilled Nursing Facility (SNF): Timeframe for MDS assessments and transmission
Special Enrollment Period
Temporary provision of HCBS by entities also providing case management services under a temporary waiver of conflict of
interest requirements
Temporary provision of HCBS in specified settings that have not been determined to meet HCBS settings criteria
Temporary suspension of fee-for-services prior authorization requirements
Temporary suspension of Pre-Admission Screening and Annual Resident Review (PASRR) Level 1 and Level 2 assessments
Transplant: Patient Care
Transplant: Payment
Transplant: Survey, Certification, Quality and Enforcement
Waive beneficiary and provider written consent of new or amended HCBS person-centered service plans
Waiver of certain provider enrollment requirements
Waiver of provider conditions to allow for provisions of services in alternative settings

Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.

What would you like to do?
Choose the applicable option below.

I want to submit a waiver / flexibility request option
When there’s a disaster or emergency, waivers and flexibilities help health care facilities
give timely care to as many people who’ve been affected as possible. This means we’re helping
States, Federal Districts and U.S. territories to make sure people with Medicare and/or Medicaid
continue to have access to care.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those
impacted by an emergency or disaster.

I want to submit an inquiry request option
When there’s a disaster or emergency, waivers and flexibilities help health care facilities give timely care to as many
people who’ve been affected as possible. This means we’re helping States, Federal Districts and U.S. territories to make
sure people with Medicare and/or Medicaid continue to have access to care.

I want to provide a status update on my patients and/or healthcare facility residents
You may use this option to report any impact on normal operations.

Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.

Provide Your Contact Information - Point of Contact
CMS uses your contact information to send responses and ask follow up questions.

Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.

Organization Information - State/US Territory/Federal District dropdown
Choose all applicable States, US Territories and/or Federal Districts where your healthcare facilities are located.

Provide Your Contact Information - Organization Categories
This provides CMS additional information on the type of organization requesting a waiver. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).

Provide Your Contact Information - Organization Identification Numbers
Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your
organization impacted by the PHE.

Describe Your 1135 Waiver / Flexibility Request
CMS uses this information to route your request to the appropriate area for faster response.

Describe Your 1135 Waiver / Flexibility Request - Waiver / Flexibility Request Type
dropdown
Start typing key words for your request. A list of waiver option(s) that match your key word(s) will
appear to choose from.

Describe Your 1135 Waiver / Flexibility Request - Regulation Related to this Request
dropdown
Cite the regulation(s) you are requesting be waived (if applicable).

CMS 1135 Waiver / Flexibility Request and Inquiry Form

Organization Workflow
CMS 1135 Inquiry Request

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 02/28/2021). 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.

Who are you?

?

An Organization / Provider

A Beneficiary

What would you like to do?

?

I want to submit a waiver / flexibility request

I want to submit an inquiry

?

?

I want to provide a status update on my beneficiaries and/or healthcare facility

?

Submit an inquiry
1 Select a Public Health Emergency

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

?

Public Health Emergency (PHE) (required) *
COVID-19

01/27/2020 - 04/20/2021

2 Provide Your Contact Information

This will help keep you updated on your request’s progress

Point of Contact

?

Who should CMS contact in response to this inquiry request?

Email address

(required) *

Confirm email address

(required) *

First name (required) *

Last name (required) *

?

Zip Code (required) *
XXXXX

Phone number
(XXX)XXX-XXXX

Organization Information ?
Who is the organization making this request?

Organization Name (required) *

Organization Categories

(required) *

?

Who is the organization making this request?

Emergency Provider / Supplier Types

General

Other

Advocacy Group

State Government

Association

Qualified Health Plan

Corporation

State Medicaid Agency

Medicare Advantage / Part D Plan

State Survey Agency
Tribal Nation

Emergency Provider / Supplier Types

General

Other

Ambulatory Surgical Center (ASC)

Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)

Community Mental Health Center
(CMHC)

Nursing Homes (SNF/NF)

Comprehensive Outpatient
Rehabilitation Facility (CORF)

Organ Procurement Organization (OPO)

Critical Access Hospital (CAH)

Outpatient Physical Therapy/Speech
Therapy (OPT/ST)

Community Mental Health Center
(CMHC)

Programs of All-Inclusive Care for
Elderly (PACE)

End Stage Renal Disease (ESRD)

Psychiatric Residential Treatment
Facility (PRTF)

Home Health Agencies (HHA)

Religious Non-Medical Health Care
Institution (RNCHI)

Hospice

Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)

Hospital

Transplant Center

Emergency Provider / Supplier Types

General

Ambulance

Palliative

Durable Medical Equipment (DME)

Physician

Lab

Other

Organization Identification Numbers

Other

Other Organization Category

?

What are the identification numbers for your organization?
These numbers will be different, depending on the categories you have
selected for your organization including: CCN/Provider, Medicare Contract
Number, or NPI.
For the categories selected above, use:

IDENTIFICATION NUMBER
Separate multiple identification numbers with a comma.

3 Inquiry
Request #1
Topic

(required) *

?

Please select an option

Type

(required) *

?

Please select an option
Click here if you do not see your type

Description

(required) *

Provide a comprehensive description of your inquiry (including regulation citations if applicable).

+ Add another inquiry request

4 Submit Your Inquiry

Submit

Thank You! Your inquiry has been successfully submitted.
Your case number is 
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.

WARNING: Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the
Privacy Act of 1974. Submission to the 1135 Waivers System that contains Protected Health Information (PHI) is a violation of these Acts. Questions
containing PHI will be deleted from the system and not processed. For detailed information regarding safeguarding protected healthcare information or
data, please refer to the ""HIPAA Security Rule"" (https://www.hhs.gov/hipaa/for-professionals/index.html).

INFORMATION NOT TO BE RELEASED TO PUBLIC UNLESS AUTHORIZED BY LAW: This information is for internal Government use only and has not been
publicly disclosed. It may contain information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share
Publicly Identifiable Information (PII) and/or Public Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of the
law.

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

Drop down options
PHE
COVID-19

01/27/2020 - 04/20/2021

Topic
Medicaid/CHIP
Original Medicare (Part A or B)
Medicare Advantage/Prescription Drug Plan
Qualified Health Plans

Type
638 Tribal Clinics
Original Medicare (Part A or B)
Academia
Medicare Advantage/Prescription Drug Plan
Access To Care
Qualified Health Plans
Advocate
Ambulance
Ambulatory Care Center
Appeals
Appendix K
Association/Society for Provider/Facility
Attorney for Provider/Facility
Billing Agency
Consultant for Provider/Facility
Critical Access Hospital
Denials
Dialysis Facility
Eligibility
Employer
Facility
Fair Hearings
Federal/State Government Agency
Federally Qualified Health Center (FQHC)
General Public
HCBS Waivers
Home Health
Hospice
Hospital
Insurance Company
Long Term Care Services And Supports
Managed Care
Medical Supplier/DME
Nurse/Nurse Practitioner
Nursing Home
Other
Payment Methodology/Rates
Pharmacist/Pharmacy
Physical/Occupational Therapy
Physician
Physician Assistant
Provider – Mental Health
Provider - Other
Provider Enrollment
Respite
Retainer Payments
Rural Health Clinic
Rural Health Clinic (RHC)
Skilled Nursing Facility
State Agency
Telehealth

Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.

What would you like to do?
Choose the applicable option below.

I want to submit a waiver / flexibility request option
When there’s a disaster or emergency, waivers and flexibilities help health care facilities
give timely care to as many people who’ve been affected as possible. This means we’re helping
States, Federal Districts and U.S. territories to make sure people with Medicare and/or Medicaid
continue to have access to care.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of
those impacted by an emergency or disaster.

I want to submit an inquiry request option
When there’s a disaster or emergency, waivers and flexibilities help health care facilities give timely care to as many
people who’ve been affected as possible. This means we’re helping States, Federal Districts and U.S. territories to make
sure people with Medicare and/or Medicaid continue to have access to care.

I want to provide a status update on my patients and/or healthcare facility residents
You may use this option to report any impact on normal operations.

Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.

Point of Contact
CMS uses your contact information to send responses and ask follow up questions.

Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.

Zip Code
Please enter your 5 digit zip code.

Organization Categories
This provides CMS additional information on the type of organization requesting a inquiry. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).

Organization Identification Numbers
Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your
organization impacted by the PHE.

Inquiry - Type dropdown
Choose your inquiry type from the dropdown list.

Inquiry - Topic dropdown
Choose from the dropdown list which category your inquiry would fall under.

CMS 1135 Waiver / Flexibility Request and Inquiry Form

Beneficiary Workflow
CMS 1135 Inquiry Request

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 02/28/2021). 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.

Who are you?

?

An Organization / Provider

A Beneficiary

What would you like to do?

?

I want to submit a waiver / flexibility request
I want to submit an inquiry

?

?

I want to provide a status update on my beneficiaries and/or healthcare facility

?

Submit an inquiry
1 Select a Public Health Emergency

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

?

Public Health Emergency (PHE) (required) *
COVID-19

01/27/2020 - 04/20/2021

2 Provide Your Contact Information

This will help keep you updated on your request’s progress

Point of Contact

?

Who should CMS contact in response to this inquiry request?

Email address

(required) *

Confirm email address

(required) *

First name (required) *

Last name (required) *

?

Zip Code (required) *
XXXXX

Phone number
(XXX)XXX-XXXX

Organization Information ?
Who is the organization making this request?

Organization Name (required) *

Organization Categories

(required) *

?

Who is the organization making this request?

Emergency Provider / Supplier Types

General

Other

Advocacy Group

State Government

Association

Qualified Health Plan

Corporation

State Medicaid Agency

Medicare Advantage / Part D Plan

State Survey Agency
Tribal Nation

Emergency Provider / Supplier Types

General

Other

Ambulatory Surgical Center (ASC)

Intermediate Care Facility for Individuals
with Intellectual Disabilities (ICF/IID)

Community Mental Health Center
(CMHC)

Nursing Homes (SNF/NF)

Comprehensive Outpatient
Rehabilitation Facility (CORF)

Organ Procurement Organization (OPO)

Critical Access Hospital (CAH)

Outpatient Physical Therapy/Speech
Therapy (OPT/ST)

Community Mental Health Center
(CMHC)

Programs of All-Inclusive Care for
Elderly (PACE)

End Stage Renal Disease (ESRD)

Psychiatric Residential Treatment
Facility (PRTF)

Home Health Agencies (HHA)

Religious Non-Medical Health Care
Institution (RNCHI)

Hospice

Rural Health Clinic/Federally Qualified
Health Center (RHC/FQHC)

Hospital

Transplant Center

Emergency Provider / Supplier Types

General

Ambulance

Palliative

Durable Medical Equipment (DME)

Physician

Lab

Other

Organization Identification Numbers

Other

Other Organization Category

?

What are the identification numbers for your organization?
These numbers will be different, depending on the categories you have
selected for your organization including: CCN/Provider, Medicare Contract
Number, or NPI.
For the categories selected above, use:

IDENTIFICATION NUMBER
Separate multiple identification numbers with a comma.

3 Inquiry
Request #1
Topic

(required) *

?

Please select an option

Type

(required) *

?

Please select an option
Click here if you do not see your type

Description

(required) *

Provide a comprehensive description of your inquiry (including regulation citations if applicable).

+ Add another inquiry request

4 Submit Your Inquiry

Submit

Thank You! Your inquiry has been successfully submitted.
Your case number is 
You will also receive an email confirmation summarizing your request and providing you with additional
guidance.

WARNING: Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the
Privacy Act of 1974. Submission to the 1135 Waivers System that contains Protected Health Information (PHI) is a violation of these Acts. Questions
containing PHI will be deleted from the system and not processed. For detailed information regarding safeguarding protected healthcare information or
data, please refer to the ""HIPAA Security Rule"" (https://www.hhs.gov/hipaa/for-professionals/index.html).

INFORMATION NOT TO BE RELEASED TO PUBLIC UNLESS AUTHORIZED BY LAW: This information is for internal Government use only and has not been
publicly disclosed. It may contain information that is privileged, confidential, or otherwise protected from disclosure under public law. Do not share
Publicly Identifiable Information (PII) and/or Public Health Information (PHI). Unauthorized disclosure may result in prosecution to the full extent of the
law.

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

Drop down options
PHE
COVID-19

01/27/2020 - 04/20/2021

Topic
Medicaid/CHIP
Original Medicare (Part A or B)
Medicare Advantage/Prescription Drug Plan
Qualified Health Plans

Type
638 Tribal Clinics
Original Medicare (Part A or B)
Academia
Medicare Advantage/Prescription Drug Plan
Access To Care
Qualified Health Plans
Advocate
Ambulance
Ambulatory Care Center
Appeals
Appendix K
Association/Society for Provider/Facility
Attorney for Provider/Facility
Billing Agency
Consultant for Provider/Facility
Critical Access Hospital
Denials
Dialysis Facility
Eligibility
Employer
Facility
Fair Hearings
Federal/State Government Agency
Federally Qualified Health Center (FQHC)
General Public
HCBS Waivers
Home Health
Hospice
Hospital
Insurance Company
Long Term Care Services And Supports
Managed Care
Medical Supplier/DME
Nurse/Nurse Practitioner
Nursing Home
Other
Payment Methodology/Rates
Pharmacist/Pharmacy
Physical/Occupational Therapy
Physician
Physician Assistant
Provider – Mental Health
Provider - Other
Provider Enrollment
Respite
Retainer Payments
Rural Health Clinic
Rural Health Clinic (RHC)
Skilled Nursing Facility
State Agency
Telehealth

Help Tooltips
Who are you?
This information helps CMS understand who you are so we can better assist you.

What would you like to do?
Choose the applicable option below.

I want to submit a waiver / flexibility request option
When there’s a disaster or emergency, waivers and flexibilities help health care facilities
give timely care to as many people who’ve been affected as possible. This means we’re helping
States, Federal Districts and U.S. territories to make sure people with Medicare and/or Medicaid
continue to have access to care.
“Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act)
or its implementing regulations that may be waived or modified under the authority of § 1135 of the
Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current
authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS
will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of
those impacted by an emergency or disaster.

I want to submit an inquiry request option
When there’s a disaster or emergency, waivers and flexibilities help health care facilities give timely care to as many
people who’ve been affected as possible. This means we’re helping States, Federal Districts and U.S. territories to make
sure people with Medicare and/or Medicaid continue to have access to care.

I want to provide a status update on my patients and/or healthcare facility residents
You may use this option to report any impact on normal operations.

Select a Public Health Emergency
Select the applicable Public Health Emergency from the dropdown list.

Point of Contact
CMS uses your contact information to send responses and ask follow up questions.

Organization Information
An organization is an organized body of people with a particular purpose (e.g., State,
Corporation, Health System, etc.). Please provide the required information for your organization.

Zip Code
Please enter your 5 digit zip code.

Organization Categories
This provides CMS additional information on the type of organization requesting a inquiry. Please
select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).

Organization Identification Numbers
Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your
organization impacted by the PHE.

Inquiry - Type dropdown
Choose your inquiry type from the dropdown list.

Inquiry - Topic dropdown
Choose from the dropdown list which category your inquiry would fall under.