Information Collection

On-Site Inspection for Durable Medical Equipment (DME) Supplier Location and Supporting Regulations in 42 CFR, Section 424.57

IC 8454 under ICR 201910-0938-009 · OMB 0938-0749.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0749 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-263 On-Site Inspection for Durable Medical Equipment (DME) Supplier Location and Supporting Regulations in 42 CFR, Section 424.57	Form and Instruction
CMS-R-263 DMEPOS Site Visit Form CMS-R-263 - NSC MAC Site Visit Inspection Form.pdf	Form and Instruction
CMS-R-263 - Appendix A - Site Investigation (DMEPOS).docx Supplier Standards Medicare DMEPOS suppliers	IC Document

IC Title:

On-Site Inspection for Durable Medical Equipment (DME) Supplier Location and Supporting Regulations in 42 CFR, Section 424.57

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 424.57

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-R-263	DMEPOS Site Visit Form	CMS-R-263 - NSC MAC Site Visit Inspection Form.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,255

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	8,255	-21,745	30,000
Annual IC Time Burden (Hours)	8,255	-6,745	15,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supplier Standards Medicare DMEPOS suppliers	CMS-R-263 - Appendix A - Site Investigation (DMEPOS).docx	11/13/2019

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