Practitioners, PMD Suppliers, and Advocates

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⚠️ Notice: This information collection may be referencing outdated material.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 Revised PMD Stakeholders Screening and Scheduling Guide Revised PMD Stakeholders Screening and Scheduling Guide.docx Form and Instruction
CMS-10471.Qualitative Research Protocols - Advocates.docx CMS-10471 IC Document
CMS-10471.Qualitive Research Protocols-Practitioners.docx CMS-10471 IC Document

Information Collection (IC) Details

IC Title:	Practitioners, PMD Suppliers, and Advocates	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Revised PMD Stakeholders Screening and Scheduling Guide	Revised 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: 254	Number of Respondents for Small Entity: 96

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	254	254
Annual IC Time Burden (Hours)	288	288
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10471	CMS-10471.Qualitative Research Protocols - Advocates.docx	10/23/2013
CMS-10471	CMS-10471.Qualitive Research Protocols-Practitioners.docx	10/23/2013

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