Information Collection

Oxygen and Supplies

IC 221459 under ICR 201605-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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-484 Oxygen and Supplies	Form and Instruction
CMS-484 Certificate of Medical Necessity - Oxygen CMS-484 Oxygen.pdf	Form and Instruction

IC Title:

Oxygen and Supplies

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-484	Certificate of Medical Necessity - Oxygen	CMS-484 Oxygen.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,632,000	1,632,000
Annual IC Time Burden (Hours)	326,400	326,400
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.