Prescription And Authorization For Fee Basis Eyeglasses

Claim, Authorization & Invoice for Prosthetic Items & Services

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.