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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.