Information Collection

Ambulance Prior Authorization

IC 240694 under ICR 202307-0938-007 · OMB 0938-1380.

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
CMS-10708 Ambulatory Prior Authorization CMS-10708 Ambo Prior Auth Instrument.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

CPI-10708

Is this a Common Form? No

IC Status: Modified

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: 1,580

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	83,374	-133,006	216,380
Annual IC Time Burden (Hours)	46,427	-67,279	113,706
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.