Notice to Reviewer

NOTICE TO REVIEWER

Date: October 17, 2015

Request Type:  No material or non-substantive change to a currently approved collection

Employing Agency:  Office of Workers’ Compensation Programs/Division of Coal Mine Workers’ Compensation (DCMWC)

Form Number/Name: CM-893, Certificate of Medical Necessity

OMB/Expiration Date:  1240-0024, February 28, 2018

Justification:

Minor changes have been made to CM-893 to provide clearer language so medical providers can better understand what information they need to provide. These changes have are shown in the 1240-0024 Mock up CM-893 supplementary document on the supplementary documents portion of the ICR documents screen.