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Agenda
Reg Review
ICR
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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