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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.