Form Cms-10069 - Medicare Waiver Demonstration Application

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U.S. 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 it

displays 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, gather

the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or

suggestions for improving this form, please write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-10069 (12/2010)