Information Collection

Ambulance Prior Authorization

IC 240694 under ICR 202003-0938-006 · OMB 0938-1380.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1380 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10708 Ambulance Prior Authorization	Form and Instruction
CMS-10708 Ambulatory Prior Authorization CMS-10708 - Ambo Prior Auth Instrument.pdf	Form and Instruction

IC Title:

Ambulance Prior Authorization

Agency IC Tracking Number:

CPI-10708

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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-10708	Ambulatory Prior Authorization	CMS-10708 - Ambo Prior Auth Instrument.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,745

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	216,380	216,380
Annual IC Time Burden (Hours)	113,706	113,706
Annual IC Cost Burden (Dollars)	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.