Prosthetic Service Card Invoice

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⚠️ Notice: This information collection may be referencing outdated material.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 10-2520 PROSTHETIC SERVICE CARD INVOICE Form
10-2520 PROSTHETIC SERVICE CARD INVOICE 10-2520-03 14.pdf Form

Information Collection (IC) Details

IC Title:	PROSTHETIC SERVICE CARD INVOICE	Agency IC Tracking Number:	10-2520

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	10-2520	PROSTHETIC SERVICE CARD INVOICE	10-2520-03 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: 700	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	700	700
Annual IC Time Burden (Hours)	47	47
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.