Information Collection Request

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

ICR 202405-0938-028 · OMB 0938-1384 · Received in OIRA

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document Name	Status
Form CMS-10752 Acute Hospital Care at Home Form and Instruction	Modified
Form CMS-10752 1135 Waiver Request Automated Process Form and Instruction	Modified
CMS 10752 .SupportingStatementPartA (30-day).docx Supporting Statement A	2024-05-31
CMS 10752 Non-Substantive Change_2023 Hurricane Idalia.docx Justification for No Material/Nonsubstantive Change	2023-08-29

IC Document Collections

IC ID	Document Title	Status
245795	Acute Hospital Care at Home Form and Instruction	Modified
243968	1135 Waiver Request Automated Process Form and Instruction	Modified

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1384
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202308-0938-016
Agency Tracking No	CCSQ
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31