Applications for Motor Vehicle Adaptive Equipment and HISA Services

OMB 2900-0188

Used to determine eligibility, prescribe, authorize and pay for prosthetic devices and glasses, obtain estimates, allow direct purchase and obtain information on loaned devices.

The latest form for Applications for Motor Vehicle Adaptive Equipment and HISA Services expires 2020-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 10-0103 Applications for Motor Vehicle Adaptive Equipment and HISA Services Form
30-day FRN_2900-0188_Applications for Motor Vehicle Adaptive Equipment and HISA Services_published 0506024.pdf Supplementary Document
60-day FRN_2900-0188_Applications for Motor Vehicle Adaptive Equipment and HISA Services_pub 02282024.pdf Supplementary Document
SSA_2900-0188_Applications for Motor Vehicle Adaptive Equipment and HISA Services_updated May 2024.docx Supporting Statement A
Applications for Motor Vehicle Adaptive Equipment and HISA Services Form

All Historical Document Collections

202402-2900-018 Approved without change	Reinstatement with change of a previously approved collection	2024-05-06
201708-2900-026 Approved without change	Revision of a currently approved collection	2017-10-31
201406-2900-004 Approved without change	Extension without change of a currently approved collection	2014-08-25
201305-2900-018 Withdrawn and continue	Revision of a currently approved collection	2014-03-13
201007-2900-001 Approved without change	Extension without change of a currently approved collection	2010-12-21
200907-2900-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2009-10-05
200707-2900-035 Approved without change	Extension without change of a currently approved collection	2007-11-01
200409-2900-003 Approved without change	Extension without change of a currently approved collection	2004-09-02
200108-2900-008 Approved without change	Extension without change of a currently approved collection	2001-08-10
199811-2900-010 Approved without change	Revision of a currently approved collection	1998-11-16
199803-2900-003 Approved without change	Extension without change of a currently approved collection	1998-03-12
199508-2900-014 Approved without change	Reinstatement without change of a previously approved collection	1995-08-23
199112-2900-004 Approved without change	Revision of a currently approved collection	1991-12-06
199009-2900-010 Approved without change	Revision of a currently approved collection	1990-09-21
198805-2900-004 Approved without change	Reinstatement with change of a previously approved collection	1988-05-10
198510-2900-003 Approved with change	No material or nonsubstantive change to a currently approved collection	1985-10-01
198507-2900-005 Approved with change	No material or nonsubstantive change to a currently approved collection	1985-07-16
198503-2900-002 Approved without change	Reinstatement with change of a previously approved collection	1985-03-20
198409-2900-047 Approved with change	No material or nonsubstantive change to a currently approved collection	1984-09-25
198110-2900-007 Approved without change	Revision of a currently approved collection	1981-10-15
198104-2900-021 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-04-09
197710-2900-005 Approved without change	Revision of a currently approved collection	1977-10-14
197706-2900-009 Approved with change	No material or nonsubstantive change to a currently approved collection	1977-06-27
197701-2900-024 Approved with change	No material or nonsubstantive change to a currently approved collection	1977-01-24