Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
HospitalRegistrationRenewal New 3198 800 0 Form and Instruction 32 HospitalRegistrationRenewal
Account Discrepancy Modified 41 10 0 Form and Instruction 30 Account Discrepancy
Accreditation Modified 12 9 0 Form and Instruction 6 Accreditation
Agent Registration (Initial) Modified 37 37 0 Form and Instruction 26 Agent Registration (Initial)
Agent Registration (Renewal & Update) Modified 3198 800 0 Form and Instruction 27 Agent Registration (Renewal & Update)
Authorized Agent Designation Modified 788 197 0 Form and Instruction 29 Authorized Agent Designation
Civil Judgment Modified 14 11 0 Form and Instruction 13 Civil Judgment
Continuous Query Modified 629921 40693 0 Form and Instruction 21 Continuous Query
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 37667 5126 0 Form and Instruction 1 Correction, Revision to Action, Correction of Revision to Action, Void, Notice of Appeal
Corrective Action Plan (Entity) New 10 1 0 Form and Instruction 36 Corrective Action Plan (Entity)
Criminal Conviction (Guilty Plea or Trial) Modified 2245 981 0 Form and Instruction 9 Criminal Conviction (Guilty Plea or Trial)
DEA/Federal Licensure Modified 114 86 0 Form and Instruction 4 DEA/Federal Licensure
Deferred Conviction or Pre-Trial Diversion Modified 50 38 0 Form and Instruction 10 Deferred Conviction or Pre-Trial Diversion
Electronic Transfer of Funds (ETF) Authorization Modified 566 45 0 Form and Instruction 28 Electronic Transfer of Funds (ETF) Authorization
Entity Registration (Initial) Modified 524 524 0 Form and Instruction 24 Entity Registration (Initial)
Entity Registration (Renewal & Update) Modified 6383 1596 0 Form and Instruction 25 Entity Registration (Renewal & Update)
Exclusion/Debarment Modified 6279 891 0 Form and Instruction 14 Exclusion/Debarment
Government Administrative Modified 2233 1675 0 Form and Instruction 15 Government Administrative
Health Plan Action Modified 524 393 0 Form and Instruction 16 Health Plan Action
HospitalRegistrationInitial New 37 37 0 Form and Instruction 31 31 HospitalRegistrationInitial
Injunction Modified 10 8 0 Form and Instruction 12 Injunction
LicensingBoardAttestation New 354 354 0 Form and Instruction 35 LicensingBoardAttestation
LicensingBoardDataRequest New 140 1470 0 Form and Instruction 33 LicensingBoardDataRequest
Medical Malpractice Payment Modified 12863 9460 0 Form and Instruction 2 Medical Malpractice Payment
Nolo Contendere (no contest) plea Modified 80 60 0 Form and Instruction 11 Nolo Contendere (no contest) plea
One Time Query for an Individual Modified 4144033 159115 0 Form and Instruction 17 One Time Query for an Individual
One Time Query for an Organization Modified 42186 3195 0 Form and Instruction 18 One Time Query for an Organization
Peer Review Organization Modified 10 8 0 Form and Instruction 5 Peer Review Organization
Professional Society Modified 50 38 0 Form and Instruction 8 Professional Society
ReconcilingMissingActionForm New 2176 174 0 Form and Instruction 37 ReconcilingMissingActionForm
ReportingDiscrepancyLetter New 389 1556 0 Form and Instruction 34 ReportingDiscrepancyLetter
Request for Secretarial Review Modified 94 752 0 Form and Instruction 23 Request for Secretarial Review
Self-Query on an Individual Modified 77318 32474 0 Form and Instruction 19 Self-Query on an Individual
Self-Query on an Organization Modified 427 427 0 Form and Instruction 20 Self-Query on an Organization
State Licensure Modified 34192 12583 0 Form and Instruction 3 State Licensure
Subject Statement and Dispute Modified 3501 2626 0 Form and Instruction 22 Subject Statement and Dispute
Title IV Clinical Privileges Actions Modified 671 503 0 Form and Instruction 7 Title IV Clinical Privileges Actions
Total burden requested under this ICR: 5012335 278753 0  
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