Information Collection

On-Site Inspection for Durable Medical Equipment (DME) Supplier Location and Supporting Regulations in 42 CFR, Section 424.57

IC 8454 under ICR 202408-0938-034 · OMB 0938-0749.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-263 On-Site Inspection for Durable Medical Equipment (DME) Supplier Location and Supporting Regulations in 42 CFR, Section 424.57	Form and Instruction
CMS-R-263 DMEPOS Site Visit Form CMS-R-263-072524.pdf	Form and Instruction
CMS-R-263 - Appendix A - Site Investigation (DMEPOS).docx Supplier Standards Medicare DMEPOS suppliers	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 424.57

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-R-263	DMEPOS Site Visit Form	CMS-R-263-072524.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,029

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	16,029	7,774	8,255
Annual IC Time Burden (Hours)	16,029	7,774	8,255
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supplier Standards Medicare DMEPOS suppliers	CMS-R-263 - Appendix A - Site Investigation (DMEPOS).docx	11/13/2019

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