Certificate of Medical Necessity

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0024 can be found here:

Documents and Forms

Document Name Document Type
Form CM-893 Certificate of Medical Necessity Form and Instruction
CM-893 Certificate of Medical Necessity 1240-0024 Certification of Medical Necessity (CM-893).pdf www.dol.gov/owcp/regs/compliance/CM-893.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certificate of Medical Necessity	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.701 20 CFR 725.707 20 CFR 725.706

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-893	Certificate of Medical Necessity	1240-0024 Certification of Medical Necessity (CM-893).pdf	http://www.dol.gov/owcp/regs/compliance/CM-893.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/OWCP-2	FR Citation: 67 FR 16869

Number of Respondents: 1,500	Number of Respondents for Small Entity: 340

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	563	563
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.