Information Collection

Certificate of Medical Necessity

IC 13782 under ICR 202311-1240-006 · OMB 1240-0024.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-893 Certificate of Medical Necessity	Form
CM-893 Certification of Medical Necessity CM-893 Form BFOTS 2.28.24.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
CM-893 Certification of Medical Necessity CM-893 Form BFOTS 2.28.24.docx www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form

IC Title:

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	Certification of Medical Necessity	CM-893 Form BFOTS 2.28.24.docx	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

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: 1,500

Number of Respondents for Small Entity: 340

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

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