Medicare Program: Conditions of Payment of Power Mobility Devices, Including Power Wheelchairs and Power-Operated Vehicles (CMS-3017-IFC)

Forms and Documents

Document Name	Status
CMS-10116.Response_Terms of Clearance FINAL 010909.pdf Supplementary Document	2009-06-04
CMS-10116.Dear Physician Letter.pdf Supplementary Document	2009-06-04
CMS-10116.Supporting Statement - Part A-PRA FINAL-1-9-09.pdf Supporting Statement A	2009-06-04

IC Document Collections

IC ID	Document Title	Status
43674	Medicare Program: Conditions of Payment of Power Mobility Devices, Including Power Wheelchairs and Power-Operated Vehicles (CMS-3017-IFC)	Modified
182114	Medicare Program: Conditions of Payment of Power Mobility Devices, Including Power Wheelchairs and Power-Operated Vehicles (CMS-3017-IFC)	Modified

ICR Details

OMB Control No: 0938-0971	ICR Reference No: 200906-0938-004
Status: Historical Active	Previous ICR Reference No: 200709-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Program: Conditions of Payment of Power Mobility Devices, Including Power Wheelchairs and Power-Operated Vehicles (CMS-3017-IFC)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/12/2010
	Date Received in OIRA: 06/09/2009
Terms of Clearance: Upon resubmission, CMS will provide industry guidance related to the provisions associated with this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2012	36 Months From Approved	04/30/2010
Responses	480,650	0	486,000
Time Burden (Hours)	48,065	0	48,600
Cost Burden (Dollars)	0	0	0

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Abstract: This collection requires physicians or treating practitioners to provide a written prescription and supporting documentation, including pertinent parts of the beneficiary's medical record to suppliers. This collection also requires the supplier to maintain the prescription and the supporting documentation provided by the physician or treating practitioners and makes them available to CMS and its agents upon request.

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Authorizing Statute(s): US Code: 42 USC 1395(l) Name of Law: Payment of benefits
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 7232	02/13/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 20318	05/01/2009
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Medicare Program: Conditions of Payment of Power Mobility Devices, Including Power Wheelchairs and Power-Operated Vehicles (CMS-3017-IFC)
Medicare Program: Conditions of Payment of Power Mobility Devices, Including Power Wheelchairs and Power-Operated Vehicles (CMS-3017-IFC)

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	480,650	486,000	0	0	-5,350	0
Annual Time Burden (Hours)	48,065	48,600	0	0	-535	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/09/2009

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