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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.