Attending Physician's Certification of Medical Necessity for Home Oxygen Therapy and Supporting Regulations -- 42 CFR 410.38 and 42 CFR 424.5, Form Number HCFA-484
ICR 199704-0938-005
OMB: 0938-0534
Federal Form Document
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0534 can be found here:
Attending Physician's
Certification of Medical Necessity for Home Oxygen Therapy and
Supporting Regulations -- 42 CFR 410.38 and 42 CFR 424.5, Form
Number HCFA-484
Reinstatement with change of a previously approved collection
This form is used to determine if
oxygen is reasonable and necessary pursuant to Medicare statute.
Medicare claims for home oxygen therapy must be supported by the
treating physician's statement and other information, including
estimate length of need (# of months), diagnosis codes (ICD-9),
etc.
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.