CERTIFICATE OF MEDICAL NECESSITY (CMN)

ICR 198407-1215-010

OMB: 1215-0113

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
122179 Migrated
ICR Details
1215-0113 198407-1215-010
Historical Active 198309-1215-037
DOL/ESA
CERTIFICATE OF MEDICAL NECESSITY (CMN)
Revision of a currently approved collection   No
Regular
Approved without change 08/23/1984
Retrieve Notice of Action (NOA) 07/23/1984
  Inventory as of this Action Requested Previously Approved
08/31/1987 08/31/1987 09/30/1984
20,000 0 8,000
6,333 0 9,598
0 0 0

THE CM-893 IS USED TO DETERMINE IF THE MINER ENTITLED TO MEDICAL TREATMENT BENEFITS, ALSO MEETS THE SPECIFIC DISABILITY STANDARDS TO TO QUALIFY FOR PULMONARY REHABILITATION, RESPIRATORY THERAPY, OR APPROVED DURABLE MEDICAL EQUIPMENT.

None
None


No

1
IC Title Form No. Form Name
CERTIFICATE OF MEDICAL NECESSITY (CMN) CM-893

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 20,000 8,000 0 -13,996 25,996 0
Annual Time Burden (Hours) 6,333 9,598 0 3,808 -7,073 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/23/1984


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