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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