Certificate of Medical Necessity

ICR 200509-1215-003

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
13782 Migrated
ICR Details
1215-0113 200509-1215-003
Historical Active 200209-1215-004
DOL/ESA
Certificate of Medical Necessity
Extension without change of a currently approved collection   No
Regular
Approved without change 12/05/2005
Retrieve Notice of Action (NOA) 09/13/2005
  Inventory as of this Action Requested Previously Approved
12/31/2008 12/31/2008 12/31/2005
4,000 0 12,000
1,567 0 4,800
0 0 0

The Certificate of Medical Necessity is completed by the coal miner's doctor and is used by DCMWC to determine if the miner meets impairment standards to qualify for durable medical equipment, home nursing, and/or pulmonary rehabilitation.

None
None


No

1
IC Title Form No. Form Name
Certificate of Medical Necessity 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 4,000 12,000 0 0 -8,000 0
Annual Time Burden (Hours) 1,567 4,800 0 0 -3,233 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.
09/13/2005


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