Certificate of Medical Necessity

OMB 1240-0024

Request for address change. The Certificate of Medical Necessity is completed by the coal miner's doctor and is used by OWCP to determine if the miner meets impairment standards to qualify for durable medical equipment or home nursing.

The latest form for Certificate of Medical Necessity expires 2021-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CM-893 Certificate of Medical Necessity Form
SS 1240-0024 CM-893 2023 final.docx Supporting Statement A
20 CFR 725.707.pdf Supplementary Document
20 CFR 725.706.pdf Supplementary Document
20 CFR 725.705.pdf Supplementary Document
20 CFR 725.701.pdf Supplementary Document
30 USC Subchapter IV (Sections 901-951).pdf Supplementary Document
System of Record Notice.pdf Supplementary Document
Certificate of Medical Necessity Form

All Historical Document Collections

202311-1240-006	Revision of a currently approved collection	2024-03-25
202012-1240-007 Approved without change	Extension without change of a currently approved collection	2021-03-15
202008-1240-041 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-10-20
202002-1240-007 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-02-21
201710-1240-002 Approved without change	Revision of a currently approved collection	2018-03-01
201508-1240-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-10-17
201410-1240-001 Approved without change	Revision of a currently approved collection	2014-11-18
201108-1240-001 Approved without change	Revision of a currently approved collection	2011-10-31
201003-1240-024 Approved without change	Extension without change of a currently approved collection	2010-03-12