State and Local governments

Medicare Prior Authorization of Power Mobility Devices (PMDs) Demonstration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1235 can be found here:

Documents and Forms

Document Name Document Type
CMS-10471.Background Research Discussion Guide.docx Instruction
CMS-10471 PMD Stakeholders Screening and Scheduling Guide CMS-10471.PMD Stakeholders Screening and Scheduling Guide .docx Form and Instruction

Information Collection (IC) Details

IC Title:	State and Local governments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10471.Background Research Discussion Guide.docx		Yes	No	Fillable Fileable
Form and Instruction	CMS-10471	PMD Stakeholders Screening and Scheduling Guide	CMS-10471.PMD Stakeholders Screening and Scheduling Guide .docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	28	28
Annual IC Time Burden (Hours)	35	35
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.