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-10126 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

IC Title:

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

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
No associated records found

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