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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
Modified
10
1
0
Form and Instruction
39
Account Balance Transfer_0915-0126.pdf
Account Discrepancy
Modified
85
21
0
Form and Instruction
35
Account Discrepancy_0915-0126.pdf
Accreditation
Modified
10
8
0
Form and Instruction
6
Accreditation Report_0915-0126.pdf
Agent Registration (Initial)
Modified
44
44
0
Form and Instruction
31
Agent Registration (Initial)_0915-0126.pdf
Agent Registration (Renewal & Update)
Modified
304
24
0
Form and Instruction
32
Agent Registration (Renewal & Update)_0915-0126.pdf
Authorized Agent Attestation
Modified
350
350
0
Form and Instruction
26
Authorized Agent Attestation_0915-0126.pdf
Authorized Agent Designation
Modified
183
46
0
Form and Instruction
34
Authorized Agent Designation_0915-0126.pdf
Civil Judgment
Modified
9
7
0
Form and Instruction
13
Civil Judgment_0915-0126.pdf
Continuous Query
Modified
1425972
64744
0
Form and Instruction
21
Continuous Query_0915-0126.pdf
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal
Modified
30219
2985
0
Form and Instruction
1
Correction Revision-to-Action Void Notice of Appeal_0915-0126.pdf
Corrective Action Plan (Entity)
Modified
10
1
0
Form and Instruction
29
Corrective Action Plan (Entity)_0915-0126.pdf
Criminal Conviction (Guilty Plea or Trial)
Modified
1857
882
0
Form and Instruction
9
Criminal Conviction (Guilty Plea or Trial)_0915-0126.pdf
DEA/Federal Licensure
Modified
600
450
0
Form and Instruction
4
DEA_Federal Licensure_0915-0126.pdf
Deferred Conviction or Pre-Trial Diversion
Modified
70
53
0
Form and Instruction
10
Deferred Conviction or Pre-Trial Diversion_0915-0126.pdf
Education Request
Modified
40
3
0
Form and Instruction
38
Education Request_0915-0126.pdf
Electronic Transfer of Funds (EFT) Authorization
Modified
644
52
0
Form and Instruction
33
Electronic Funds Transfer (EFT) Authorization_0915-0126.pdf
Entity Registration (Initial)
Modified
3484
3484
0
Form and Instruction
24
Entity Registration (Initial)_0915-0126.pdf
Entity Registration (Renewal & Update)
Modified
13245
3311
0
Form and Instruction
25
Entity Registration (Renewal & Update)_0915-0126.pdf
Exclusion/Debarment
Modified
4213
1281
0
Form and Instruction
14
Exclusion or Debarment_0915-0126.pdf
Government Administrative
Modified
1789
1314
0
Form and Instruction
15
Government Administrative_0915-0126.pdf
Health Center Attestation
New
722
722
0
Form and Instruction
41
Health Center Attestation_0915-0126.pdf
Health Plan Action
Modified
488
366
0
Form and Instruction
16
Health Plan Action_0915-0126.pdf
Hospital Attestation
New
3416
3416
0
Form and Instruction
42
Hospital Attestation_0915-0126.pdf
Injunction
Modified
10
8
0
Form and Instruction
12
Injunction_0915-0126.pdf
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation
New
274
274
0
Form and Instruction
43
Medical Malpractice Payer Attestation_0915-0126.pdf
Medical Malpractice Payment
Modified
11777
8612
0
Form and Instruction
2
Medical Malpractice Payment_0915-0126.pdf
Missing Report from Query Form
Modified
10
1
0
Form and Instruction
40
Missing Report from Query_0915-0126.pdf
New Administrator Request
Modified
600
48
0
Form and Instruction
36
New Administrator Request_0915-0126.pdf
Nolo Contendere (no contest) plea
Modified
127
95
0
Form and Instruction
11
Nolo Contendere (no contest plea)_0915-0126.pdf
One Time Query for an Individual
Modified
5307954
157659
0
Form and Instruction
17
One-Time Query for an Individual_0915-0126.pdf
One Time Query for an Organization
Modified
76291
4062
0
Form and Instruction
18
One-Time Query for an Organization_0915-0126.pdf
Other Eligible Entity Attestation
New
1884
1884
0
Form and Instruction
44
Other Eligible Entity Attestation_0915-0126.pdf
Peer Review Organization
Modified
10
8
0
Form and Instruction
5
Peer Review Organization_0915-0126.pdf
Professional Society
Modified
41
31
0
Form and Instruction
8
Professional Society_0915-0126.pdf
Purchase Query Credits
Modified
1786
143
0
Form and Instruction
37
Purchase Query Credits_0915-0126.pdf
Reconciling Missing Actions
Modified
1491
1193
0
Form and Instruction
30
Reconciling Missing Actions_0915-0126.pdf
Request for Dispute Resolution
Modified
74
592
0
Form and Instruction
23
Request for Dispute Resolution_0915-0126.pdf
Self-Query on an Individual
Modified
168557
70794
0
Form and Instruction
19
Self-Query on an Individual_0915-0126.pdf
Self-Query on an Organization
Modified
1059
445
0
Form and Instruction
20
Self-Query on an Organization_0916-0126.pdf
State Licensing Board Attestation
Modified
325
325
0
Form and Instruction
28
State Licensing Board Attestation_0915-0126.pdf
State Licensing Board Data Request
Modified
60
630
0
Form and Instruction
27
State Licensing Board Data Request_0915-0126.pdf
State Licensure
Modified
36938
14817
0
Form and Instruction
3
State Licensure or Certification_0915-0126.pdf
Subject Statement and Dispute
Modified
3264
2448
0
Form and Instruction
22
Subject Statement and Dispute_0915-0126.pdf
Title IV Clinical Privileges Actions
Modified
978
734
0
Form and Instruction
7
Title IV Clinical Privileges Actions_0915-0126.pdf
Total burden requested under this ICR:
7101274
348368
0
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