Practitioners, PMD Suppliers, and Advocates

Medicare Prior Authorization of Power Mobility Devices (PMDs) Demonstration (CMS-10471)

Documents and Forms

Document Name Document Type
CMS-10471 - Revised Background Research Discussion Guide 2017.docx Instruction
CMS-10471 Revised PMD Stakeholders Screening and Scheduling Guide CMS-10471 - Revised PMD Stakeholders Screening and Scheduling Guide.docx Form and Instruction
CMS-10471 - Revised Qualitative Research Protocols Advocates.docx CMS-10471 IC Document
CMS-10471 - Revised Qualitive Research Protocols-Practitioners-PRA Final.docx CMS-10471 IC Document

Information Collection (IC) Details

IC Title:	Practitioners, PMD Suppliers, and Advocates	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Instruction			CMS-10471 - Revised Background Research Discussion Guide 2017.docx		Yes	No	Fillable Fileable
Form and Instruction	CMS-10471	Revised PMD Stakeholders Screening and Scheduling Guide	CMS-10471 - Revised PMD Stakeholders Screening and Scheduling Guide.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 317	Number of Respondents for Small Entity: 96

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	317	63	254
Annual IC Time Burden (Hours)	447	159	288
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10471	CMS-10471 - Revised Qualitative Research Protocols Advocates.docx	05/30/2017
CMS-10471	CMS-10471 - Revised Qualitive Research Protocols-Practitioners-PRA Final.docx	05/30/2017

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