Ambulance Prior Authorization

Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model Process and Requirements (CMS-10708)

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

Information Collection (IC) Details

IC Title:	Ambulance Prior Authorization	Agency IC Tracking Number:	CPI-10708

Is this a Common Form? No		IC Status: Modified

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: 1,580	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 %

	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

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.