Certificate of Medical Necessity

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0024 can be found here:

Documents and Forms

Document Name Document Type
Form CM-893 Certificate of Medical Necessity Form and Instruction
CM-893 Certificate of Medical Necessity CM-893_working.pdf www.dol.gov/owcp/regs/compliance/cm-893.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certificate of Medical Necessity	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 725.701 20 CFR 725.707 20 CFR 725.706

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CM-893	Certificate of Medical Necessity	CM-893_working.pdf	http://www.dol.gov/owcp/regs/compliance/cm-893.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: ESA-6 and ESA-30	FR Citation: 67 FR 16869

Number of Respondents: 2,500	Number of Respondents for Small Entity: 340

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,500	0	2,500
Annual IC Time Burden (Hours)	965	0	965
Annual IC Cost Burden (Dollars)	1,460	125	1,335

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.