Information Collection

Certificate of Medical Necessity

IC 13782 under ICR 201508-1240-001 · OMB 1240-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0024 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-893 Certificate of Medical Necessity	Form and Instruction
CM-893 Certificate of Medical Necessity CM-893.pdf www.dol.gov/owcp/regs/compliance/CM-893.pdf	Form and Instruction

IC Title:

Certificate of Medical Necessity

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.707 20 CFR 725.701 20 CFR 725.706

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-893	Certificate of Medical Necessity	CM-893.pdf	http://www.dol.gov/owcp/regs/compliance/CM-893.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: ESA-6 and ESA-30

FR Citation: 67 FR 16869

Number of Respondents: 2,500

Number of Respondents for Small Entity: 340

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	965	965
Annual IC Cost Burden (Dollars)	1,460	1,460

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.