Durable Medical Equipment and Other Devices form

Durable Medical Equipment (DME).

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0559 can be found here:

Documents and Forms

Document Name Document Type
Form PC-262-3 Durable Medical Equipment and Other Devices form Form and Instruction
PC-262-3 Durable Medical Equipment Form DME Form - OMB changes.docx Form and Instruction
Justification for revised DME_Final 1_25_16.docx Justification for changes IC Document
DME Form - OMB changes.docx Changes to form IC Document

Information Collection (IC) Details

IC Title:	Durable Medical Equipment and Other Devices form	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

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	PC-262-3	Durable Medical Equipment Form	DME Form - OMB changes.docx		Yes	Yes	Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Justification for changes	Justification for revised DME_Final 1_25_16.docx	02/07/2017
Changes to form	DME Form - OMB changes.docx	02/14/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.