Certificate of Medical Necessity

ICR 200809-1215-001

OMB: 1215-0113

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2008-09-17
Supplementary Document
2008-09-09
Supplementary Document
2008-09-09
Supplementary Document
2008-09-09
IC Document Collections
IC ID
Document
Title
Status
13782 Modified
ICR Details
1215-0113 200809-1215-001
Historical Active 200509-1215-003
DOL/ESA
Certificate of Medical Necessity
Extension without change of a currently approved collection   No
Regular
Approved without change 10/28/2008
Retrieve Notice of Action (NOA) 09/24/2008
  Inventory as of this Action Requested Previously Approved
10/31/2011 36 Months From Approved 12/31/2008
3,200 0 4,000
1,253 0 1,567
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.

US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None

Not associated with rulemaking

  73 FR 31890 06/04/2008
73 FR 55134 09/24/2008
No

1
IC Title Form No. Form Name
Certificate of Medical Necessity CM-893 Certificate of Medical Necessity

  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 3,200 4,000 0 0 -800 0
Annual Time Burden (Hours) 1,253 1,567 0 0 -314 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
There has been an adjustment in the burden hours from 1,567 to 1,253 which is a decrease of -314 burden hours due to a decrease in the number of miner beneficiaries who are eligible for medical benefits. There has also been a decrease in responses from the previous submission of 4,000 to 3,200 which is a decrease of -800.

$203,476
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Michael McClaran 202-693-0978 [email protected]

  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.
09/24/2008


© 2024 OMB.report | Privacy Policy