Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Account Balance Transfer New 10 1 0 Form and Instruction 39 Account Balance Transfer.pdf
Account Discrepancy Modified 10 3 0 Form and Instruction 35 Account Discrepancy.pdf
Accreditation Modified 10 8 0 Form and Instruction 6 Accreditation.pdf
Agent Registration (Initial) Modified 85 85 0 Form and Instruction 31 Agent Registration (Initial).pdf
Agent Registration (Renewal) Modified 278 23 0 Form and Instruction 32 Agent Registration (Renewal & Update).pdf
Authorized Agent Designation Modified 213 54 0 Form and Instruction 34 Authorized Agent Designation.pdf
Civil Judgment Modified 10 8 0 Form and Instruction 13 Civil Judgment.pdf
Continuous Query Modified 870698 51578 0 Form and Instruction 21 Continuous Query.pdf
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 29080 2785 0 Form and Instruction 1 Correction, Revision to Action, Void, Notice of Appeal.pdf
Corrective Action Plan Modified 10 1 0 Form and Instruction 29 Corrective Action Plan (Entity).pdf
Criminal Conviction (Guilty Plea or Trial) Modified 1828 856 0 Form and Instruction 9 Criminal Conviction (Guilty Plea or Trial).pdf
DEA/Federal Licensure Modified 698 524 0 Form and Instruction 4 DEA_Federal Licensure.pdf
Deferred Conviction or Pre-Trial Diversion Modified 54 41 0 Form and Instruction 10 Deferred Conviction or Pre-Trial Diversion .pdf
Educational Request New 10 1 0 Form and Instruction 38 Education Request.pdf
Electronic Transfer of Funds (EFT) Authorization Modified 654 53 0 Form and Instruction 33 Electronic Transfer of Funds (EFT) Authorization.pdf
Entity Profile Modified 9000 2250 0 Form and Instruction 26 Entity Profile.pdf
Entity Registration (Initial) Modified 1073 1073 0 Form and Instruction 24 Entity Registration (Initial).pdf
Entity Registration (Renewal & Update) Modified 14060 3515 0 Form and Instruction 25 Entity Registration (Renewal & Update).pdf
Exclusion/Debarment Modified 4804 1219 0 Form and Instruction 14 Exclusion_Debarment.pdf
Government Administrative Modified 2062 1547 0 Form and Instruction 15 Government Administrative.pdf
Health Plan Action Modified 335 252 0 Form and Instruction 16 Health Plan Action.pdf
Injunction Modified 10 8 0 Form and Instruction 12 Injunction.pdf
Licensing Board Attestation Modified 301 301 0 Form and Instruction 28 FINALLicensing Board Attestation.pdf
Licensing Board Data Request Modified 146 1533 0 Form and Instruction 27 LicensingBoardDataRequest.pdf
Medical Malpractice Payment Modified 12235 8996 0 Form and Instruction 2 Medical Malpractice Payment Report.pdf
Missing Report Form New 29 3 0 Form and Instruction 40 Missing Report from Query.pdf
New Administrator Request Modified 3016 242 0 Form and Instruction 36 NewAdmin.pdf
Nolo Contendere (no contest) plea Modified 85 64 0 Form and Instruction 11 Nolo Contendere (no contest) plea.pdf
One Time Query for an Individual Modified 4867722 165195 0 Form and Instruction 17 One Time Query for an Individual.pdf
One Time Query for an Organization Modified 49896 3180 0 Form and Instruction 18 One Time Query for an Organization.pdf
Peer Review Organization Modified 10 8 0 Form and Instruction 5 Peer Review Organization.pdf
Professional Society Modified 49 37 0 Form and Instruction 8 Professional Society.pdf
Query Credit Purchase Modified 789 64 0 Form and Instruction 37 Query_Credits.pdf
Reconciling Missing Actions Modified 7981 6385 0 Form and Instruction 30 ReconcilingMissionActionForm.pdf
Request for Dispute Resolution Modified 99 792 0 Form and Instruction 23 Request for Dispute Resolution.pdf
Self-Query on an Individual Modified 131481 55223 0 Form and Instruction 19 Self-Query on an Individual.pdf
Self-Query on an Organization Modified 1545 649 0 Form and Instruction 20 Self-Query on an Organization.pdf
State Licensure Modified 45140 14378 0 Form and Instruction 3 State Licensure.pdf
Subject Statement and Dispute Modified 3547 2661 0 Form and Instruction 22 Subject Statement and Dispute.pdf
Title IV Clinical Privileges Actions Modified 698 524 0 Form and Instruction 7 Title IV Clinical Privileges Actions.pdf
Total burden requested under this ICR: 6059761 326120 0  
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