Information Collection

Certificate of Medical Necessity

IC 13782 under ICR 202012-1240-007 · OMB 1240-0024.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-893 Certificate of Medical Necessity	Form
CM-893 Certificate of Medical Necessity 20210309 Form CM-893.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms	Form
CM-893 Certificate of Medical Necessity 20210309 Form CM-893.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms	Form
Form CM-893 Tracked Changes (022021).docx Form CM-893 Tracked Changes	IC Document
Form CM-893 Tracked Changes (022021).docx Form CM-893 Tracked Changes	IC Document

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 725.707 20 CFR 725.706 20 CFR 725.705 20 CFR 725.701

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	CM-893	Certificate of Medical Necessity	20210309 Form CM-893.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: DOL/OWCP-2 and DOL/OWCP-9

FR Citation: 81 FR 25766

Number of Respondents: 1,300

Number of Respondents for Small Entity: 340

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,300	-200	1,500
Annual IC Time Burden (Hours)	488	-75	563
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Form CM-893 Tracked Changes	Form CM-893 Tracked Changes (022021).docx	03/04/2021

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