OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Medicare/Medicaid Demonstration/Model Application (CMS-10069)

OMB 0938-0880 · HHS/CMS.

OMB 0938-0880

This application provides an opportunity for States and organizations to apply for Medicare and Medicaid demonstrations/models. CMS seeks to test new demonstrations and models of care that aim to improve the quality of healthcare and lower healthcare costs through innovative approaches to service delivery and payment.

The latest form for Medicare/Medicaid Demonstration/Model Application (CMS-10069) expires 2028-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form and Instruction
Supporting Statement A
All Historical Document Collections
 Reinstatement with change of a previously approved collection 2025-06-02
Approved with change
 Extension without change of a currently approved collection 2017-02-24
Approved without change
 Extension without change of a currently approved collection 2013-12-06
Approved without change
 No material or nonsubstantive change to a currently approved collection 2013-07-30
Approved without change
 Extension without change of a currently approved collection 2010-09-26
Approved without change
 Extension without change of a currently approved collection 2007-07-13
Approved without change
 Extension without change of a currently approved collection 2006-06-22
Approved without change
 No material or nonsubstantive change to a currently approved collection 2005-08-02
Approved without change
 No material or nonsubstantive change to a currently approved collection 2004-10-29
Approved without change
 No material or nonsubstantive change to a currently approved collection 2004-10-29
Approved without change
 Extension without change of a currently approved collection 2003-05-14
Approved with change
 New collection (Request for a new OMB Control Number) 2002-08-22