Data sheet: applicant and project
Applicant legal name, address, city, county, state and ZIP code, the person to contact about the application, the descriptive title of the project, project duration (mm/dd/yyyy) and the proposed project.
CMS-10069
Medicare Waiver Demonstration Application
- Agency
- CMS
- Revision
- 12/2010
- Fillable fields
- 27
- Pages
- 5
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10069: Medicare Waiver Demonstration Application
Form CMS-10069 is the Medicare Waiver Demonstration Application from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. The form says it gives eligible organizations an opportunity to apply to participate in Medicare-waiver-only demonstrations sponsored by CMS. It describes these as tests of innovations that may involve new benefits, fee-for-service or Medicare Advantage payment methodologies, or risk sharing arrangements not currently permitted under Medicare statute.
The fillable part is a one-page Medicare Waiver Demonstration Applicant Data Sheet. The pages after it explain budget neutrality, the due date, how to submit, the order of the written application and what each part of it covers. The specific demonstration, its due date, its project officer and its evaluation criteria come from the demonstration solicitation, which the form points to throughout.
The form says applications are mailed to CMS and that fax copies are not accepted. You can fill out the data sheet free in your browser on this page and download the result without an account.
What's on Form CMS-10069
Data sheet: type and identifiers
Type of applicant, areas affected by the project (cities, counties, states), the applicant's Medicare provider number(s), Employer Identification Number and whether the applicant is a Medicare provider/organization in good standing.
Data sheet: certification and signature
A statement that the data are true and correct and authorized by the applicant's governing body, with the authorized representative's typed name and title, telephone number, signature and date signed.
Cover letter and executive summary
The cover letter identifies the demonstration, target population, geographic location, CMS provider numbers and contact person. The executive summary is a 4 page summary of the key elements of the proposal.
Problem statement and demonstration design
Current Medicare coverage and payment policy and how changes would lower costs or improve access or quality, then the intervention, payment methodology, how beneficiaries are identified and enrolled, and the study design if applicable.
Organization, results, payment and plan
Governance, teams, licenses and financial viability, performance monitoring and results, the proposed payment method with expected, best and worse case budget neutrality scenarios, an implementation plan and supplemental materials.
The form lists ten parts for the application, in order: cover letter, data sheet, executive summary, problem statement, demonstration design, organizational structure and capabilities, performance results, payment methodology and budget neutrality, implementation plan and supplemental materials.
How to put together a CMS-10069 application
- 1
Read the demonstration solicitation
The form says to refer to the solicitation for details of the demonstration, its due date in the DATES section, the project officer and the evaluation criteria.
- 2
Complete the data sheet
Fill in, sign and date the Applicant Data Sheet. If the applicant is not a Medicare provider/organization in good standing, the form asks for an attached explanation.
- 3
Write the application sections
Follow the order the form lists. The form says to type it in 12 point font with 1 inch margins, within 40 double-spaced pages, not counting the cover letter, executive summary, forms and supporting documentation.
- 4
Show budget neutrality
The form says expected costs under the demonstration cannot be more than expected costs without it, and asks for the information and assumptions CMS will use in the waiver package sent to OMB.
- 5
Prepare the copies
The form asks for an unbound original and 2 copies plus an electronic copy on CD-ROM. It says applicants may, but are not required to, submit 10 copies.
- 6
Mail it to CMS by the due date
Mail the original and all copies to the address on the form, with the project officer and demonstration names inserted. The form says applications are due by 5 P.M. EST/EDT on the due date.
Why fill Form CMS-10069 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes, deadlines and review
Where to send it
Department of Health and Human Services, Centers for Medicare & Medicaid Services, ATTN: (project officer name and name of demonstration), Medicare Demonstrations Program Group, Office of Research, Development & Information, Mail Stop C4-17-27, 7500 Security Boulevard, Baltimore, Maryland, 21244.
Due date
The form says applications are timely if received on or before the due date in the DATES section of the solicitation, by 5 P.M. EST/EDT, and that only timely applications are reviewed.
No fax
The form says CMS cannot accept applications by fax, citing staffing and resource limits and the need for an original signature.
Start-up funds
If the solicitation announces start-up funding, the form says to include Standard Forms 424 after the data sheet and give the amount requested in the cover letter.
Review
The form says CMS convenes technical review panels, which may include outside experts, to rate and rank applications numerically using the criteria in the solicitation.
Time to complete
The form estimates an average of 80 hours per response, including reviewing instructions, searching data resources and gathering the data.
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Who uses Form CMS-10069?
The form says it is for eligible organizations applying to a Medicare-waiver-only demonstration. The data sheet lists the applicant types.
Official sources and the blank
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Questions about Form CMS-10069
What is a Medicare-waiver-only demonstration?
The form describes them as CMS demonstrations that test innovations shown to improve access and quality or lower health care costs, and that may involve benefits, payment methods or risk sharing not currently permitted under Medicare statute. It cites Section 402 of Public Law 92-603 as the authority to waive Medicare payment and benefit statutes.
Where do I send Form CMS-10069?
The form gives a mailing address at CMS, Medicare Demonstrations Program Group, Mail Stop C4-17-27, 7500 Security Boulevard, Baltimore, Maryland, 21244, with the project officer and demonstration names from the solicitation in the ATTN line.
Can the application be faxed?
No. The form says CMS cannot accept applications by fax because it requires an application with an original signature.
How long can the application be?
The form says it should not exceed 40 double-spaced pages, typed in 12 point font with 1 inch margins, not counting the cover letter, executive summary, forms and supporting documentation.
What does budget neutrality mean on this form?
The form says it means the expected costs under the demonstration cannot be more than the expected costs if the demonstration did not occur. It adds that OMB approves Medicare waivers before the demonstration is implemented.
How many copies are needed?
The form asks for an unbound original and 2 copies plus an electronic copy on CD-ROM. It says applicants may, but are not required to, submit 10 copies.
How are applications reviewed?
The form says technical review panels, which may include outside experts, receive each application with a technical summary and rate and rank it using the evaluation criteria in the solicitation.