ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY

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
113938	ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY Form	Migrated

ICR Details

OMB Control No: 0938-0534	ICR Reference No: 199003-0938-006
Status: Historical Active	Previous ICR Reference No: 198901-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/22/1990
	Date Received in OIRA: 03/26/1990
Terms of Clearance: end the next submission for OMB review will carefully evaluate based on experience in the field whether this form takes on average an estimated 15 minutes per response. Any changes to the burden hours per response will be recorded as program changes. 2) the next submission for OMB review carefully assesses the costs in paperwork burden versus the benefits of using the HCFA-484 to recertify medical necessity of oxygen after three months 3) the next submission will consider changes that make the HCFA-484 less burdensome for physicians in hospital settings, i.e. allowing other qualified medical professionals such as RNs complete the form. Lastly, because this form recently was revised to reflect public comment, it will not be printed and distributed for use at the time of OMB approval. Therefore, OMB extends approval of the 1-89 version of the form through 9/90 until the new revised version of the form in this package is available for use.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/1991	09/30/1991	03/31/1990
Responses	600,000	0	600,000
Time Burden (Hours)	150,000	0	250,000
Cost Burden (Dollars)	0	0	0

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Abstract: MEDICARE COVERAGE FOR OXYGEN AND OXYGEN EQUIPMENT USED IN A PATIENT'S HOME REQUIRE THAT THE CLAIM FOR BENEFITS BE SUPPORTED BY A CERTIFICATI OF MEDICAL NECESSITY FROM THE ATTENDING PHYSICIAN. THIS STANDARD CERTIFICATION FORM HELPS TO ENSURE CONSISTENT COVERAGE DETERMINATIONS BY MEDICARE CARRIERS THROUGHOUT THE COUNTRY.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY	HCFA-484

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ICR Summary of Burden

	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	600,000	600,000	0	0	0	0
Annual Time Burden (Hours)	150,000	250,000	0	0	-100,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/26/1990

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