Information Collection

Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

IC 37897 under ICR 202002-0938-014 · OMB 0938-0679.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-854 CMS-854 -- CONTINUATION FORM Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction
Form CMS-846 CMS for PNEUMATIC COMPRESSION DEVICES Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction
Form CMS-847 CMN for OSTEOGENESIS STIMULATORS Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction
Form CMS-848 CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction
Form CMS-849 CMN for SEAT LIFT MECHANISMS Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction
Form CMS-10125 CMN for EXTERNAL INFUSION PUMPS Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction
Form CMS-10126 CMN for ENTERAL AND PARENTERAL NUTRITION Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction
CMS-854 CMS-854 -- CONTINUATION FORM CMS-854 - CONTINUATION FORM.pdf	Form and Instruction
CMS-846 CMS for PNEUMATIC COMPRESSION DEVICES CMS-846 - PNEUMATIC COMPRESSION DEVICES.pdf	Form and Instruction
CMS-847 CMN for OSTEOGENESIS STIMULATORS CMS-847 - OSTEOGENESIS STIMULATORS.pdf	Form and Instruction
CMS-848 CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS CMS-848 - TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS).pdf	Form and Instruction
CMS-849 CMN for SEAT LIFT MECHANISMS CMS-849 - SEAT LIFT MECHANISMS.pdf	Form and Instruction
CMS-10125 CMN for EXTERNAL INFUSION PUMPS CMS-10125 - EXTERNAL INFUSION PUMPS.pdf	Form and Instruction
CMS-10126 CMN for ENTERAL AND PARENTERAL NUTRITION CMS-10126 - CMN ENTERAL AND PARENTERAL NUTRITION.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10126	CMN for ENTERAL AND PARENTERAL NUTRITION	CMS-10126 - CMN ENTERAL AND PARENTERAL NUTRITION.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-854	CMS-854 -- CONTINUATION FORM	CMS-854 - CONTINUATION FORM.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-846	CMS for PNEUMATIC COMPRESSION DEVICES	CMS-846 - PNEUMATIC COMPRESSION DEVICES.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-847	CMN for OSTEOGENESIS STIMULATORS	CMS-847 - OSTEOGENESIS STIMULATORS.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-848	CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)	CMS-848 - TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS).pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-849	CMN for SEAT LIFT MECHANISMS	CMS-849 - SEAT LIFT MECHANISMS.pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-10125	CMN for EXTERNAL INFUSION PUMPS	CMS-10125 - EXTERNAL INFUSION PUMPS.pdf	Yes	No	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59,200

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	Previously Approved
Annual Number of Responses for this IC	259,597	-202,403	462,000
Annual IC Time Burden (Hours)	51,919	-40,481	92,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.