Attending Physician's Certification of Medical Necessity for Home Oxygen Therapy and Supporting Regulations 42 CFR 410.38 and 42 CFR 424.5

ICR 200502-0938-002

OMB: 0938-0534

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0534 200502-0938-002
Historical Active 200303-0938-013
HHS/CMS
Attending Physician's Certification of Medical Necessity for Home Oxygen Therapy and Supporting Regulations 42 CFR 410.38 and 42 CFR 424.5
Revision of a currently approved collection   No
Regular
Approved with change 09/16/2005
Retrieve Notice of Action (NOA) 02/02/2005
The burden associated with Medicare complex medical review was removed from this information collection and placed in 0938-0969.
  Inventory as of this Action Requested Previously Approved
09/30/2008 09/30/2008 09/30/2005
1,200,000 0 700,000
240,000 0 116,000
0 0 0

This form is used to determine of 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.

None
None


No

  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 1,200,000 700,000 0 0 500,000 0
Annual Time Burden (Hours) 240,000 116,000 0 0 124,000 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
02/02/2005


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