Information Collection

Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

IC 37897 under ICR 201410-0938-004 · OMB 0938-0679.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0679 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-854 Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation Form and Instruction
CMS-854 CMS-854 -- CONTINUATION FORM CMS854.pdf Form and Instruction
CMS-846 CMS for PNEUMATIC COMPRESSION DEVICES CMS-846.pdf Form and Instruction
CMS-847 CMN for OSTEOGENESIS STIMULATORS CMS-847_508.pdf Form and Instruction
CMS-848 CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS CMS-848.pdf Form and Instruction
CMS-849 CMN for SEAT LIFT MECHANISMS CMS-849.pdf Form and Instruction
CMS-10125 CMN for EXTERNAL INFUSION PUMPS CMS-10125-3 25.pdf Form and Instruction
CMS-10126 CMN for ENTERAL AND PARENTERAL NUTRITION CMS-10126-fillable.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-854	CMS-854 -- CONTINUATION FORM	CMS854.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-846	CMS for PNEUMATIC COMPRESSION DEVICES	CMS-846.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-847	CMN for OSTEOGENESIS STIMULATORS	CMS-847_508.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-848	CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)	CMS-848.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-849	CMN for SEAT LIFT MECHANISMS	CMS-849.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-10125	CMN for EXTERNAL INFUSION PUMPS	CMS-10125-3 25.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-10126	CMN for ENTERAL AND PARENTERAL NUTRITION	CMS-10126-fillable.pdf	Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 59,200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	462,000	462,000
Annual IC Time Burden (Hours)	92,400	92,400
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.