Information Collection

Prescription And Authorization For Fee Basis Eyeglasses

IC 210609 under ICR 201305-2900-018 · OMB 2900-0188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-2914 PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES	Form
10-2914 PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES 10-2914-03 14.pdf	Form

IC Title:

PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES

Agency IC Tracking Number:

10-2914

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-2914	PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES	10-2914-03 14.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.