Transcription of MEDICARE WAIVER DEMONSTRATION APPLICATION
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MEDICARE WAIVER DEMONSTRATION APPLICATION
Form CMS-10069 (12/2010) DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for MEDICARE & Medicaid Services MEDICARE WAIVER DEMONSTRATION APPLICATION DISCLOSURE STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless itdisplays a valid OMB control number. The valid OMB control number for this information collection is 0938-0880. The time required to complete this infor-mation collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gatherthe data needed, and complete and review the information collection.
Medicare waivers before implementing the demonstration. DUE DATE . ... reports from clinical, financial, and management information systems and describe how they will be used to support implementation. Provide copies of applicable Federal and State licenses. Indicate if the applicant is a Medicare provider in good
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