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.pdf
Account Discrepancy Modified 4 1 0 Form and Instruction 35 Account Discrepancy.pdf
Accreditation Modified 10 8 0 Form and Instruction 6 Accreditation.pdf
Agent Registration (Initial) Modified 78 78 0 Form and Instruction 31 Agent Registration (Initial).pdf
Agent Registration (Renewal & Update) Modified 318 25 0 Form and Instruction 32 Agent Registration (Renewal & Update).pdf
Authorized Agent Attestation Modified 171 171 0 Form and Instruction 26 Authorized Agent Attestation.pdf
Authorized Agent Designation Modified 183 46 0 Form and Instruction 34 Authorized Agent Designation.pdf
Civil Judgment Modified 6 5 0 Form and Instruction 13 Civil Judgment.pdf
Continuous Query Modified 1931578 82745 0 Form and Instruction 21 Continuous Query
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 23879 2230 0 Form and Instruction 1 Correction Revision-to-Action Void Notice of Appeal
Corrective Action Plan (Entity) Modified 10 1 0 Form and Instruction 29 Corrective Action Plan (Entity).pdf
Criminal Conviction (Guilty Plea or Trial) Modified 1385 736 0 Form and Instruction 9 Criminal Conviction (Guilty Plea or Trial).pdf
DEA/Federal Licensure Modified 555 416 0 Form and Instruction 4 DEA_Federal Licensure.pdf
Deferred Conviction or Pre-Trial Diversion Modified 60 45 0 Form and Instruction 10 Deferred Conviction or Pre-Trial Diversion.pdf
Education Request Modified 10 1 0 Form and Instruction 38 Education Request.pdf
Electronic Transfer of Funds (EFT) Authorization Modified 734 59 0 Form and Instruction 33 Electronic Funds Transfer (EFT) Authorization.pdf
Entity Registration (Initial) Modified 3252 3252 0 Form and Instruction 24 Entity Registration (Initial).pdf
Entity Registration (Renewal & Update) Modified 12990 3248 0 Form and Instruction 25 Entity Registration (Renewal & Update).pdf
Exclusion/Debarment Modified 3897 967 0 Form and Instruction 14 Exclusion or Debarment.pdf
Government Administrative Modified 1999 1027 0 Form and Instruction 15 Government Administrative.pdf
Health Center Attestation Modified 724 724 0 Form and Instruction 41 Health Center Attestation.pdf
Health Plan Action Modified 391 293 0 Form and Instruction 16 Health Plan Action.pdf
Hospital Attestation Modified 3238 3238 0 Form and Instruction 42 Hospital Attestation.pdf
Injunction Modified 10 8 0 Form and Instruction 12 Injunction.pdf
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Modified 267 267 0 Form and Instruction 43 Medical Malpractice Payer Attestation.pdf
Medical Malpractice Payment Modified 11527 8311 0 Form and Instruction 2 Medical Malpractice Payment.pdf
Missing Report from Query Form Modified 10 1 0 Form and Instruction 40 Missing Report from Query.pdf
New Administrator Request Modified 215 17 0 Form and Instruction 36 New Administrator Request.pdf
Nolo Contendere (no contest) plea Modified 75 56 0 Form and Instruction 11 Nolo Contendere (no contest plea).pdf
One Time Query for an Individual Modified 5735715 144413 0 Form and Instruction 17 One-Time Query for an Individual.pdf
One Time Query for an Organization Modified 111088 6179 0 Form and Instruction 18 One-Time Query for an Organization.pdf
Other Eligible Entity Attestation Modified 4790 4790 0 Form and Instruction 44 Other Eligible Entity Attestation.pdf
Peer Review Organization Modified 10 8 0 Form and Instruction 5 Peer Review Organization.pdf
Professional Society Modified 27 20 0 Form and Instruction 8 Professional Society.pdf
Purchase Query Credits Modified 5590 447 0 Form and Instruction 37 Purchase Query Credits.pdf
Reconciling Missing Actions Modified 1371 110 0 Form and Instruction 30 Reconciling Missing Actions.pdf
Request for Dispute Resolution Modified 83 664 0 Form and Instruction 23 Request for Dispute Resolution.pdf
Self-Query on an Individual Modified 223589 93907 0 Form and Instruction 19 Self-Query on an Individual.pdf
Self-Query on an Organization Modified 879 369 0 Form and Instruction 20 Self-Query on an Organization.pdf
State Licensing Board Attestation Modified 360 360 0 Form and Instruction 28 State Licensing Board Attestation.pdf
State Licensing Board Data Request Modified 87 914 0 Form and Instruction 27 State Licensing Board Data Request.pdf
State Licensure Modified 28632 10502 0 Form and Instruction 3 State Licensure or Certification.pdf
Subject Statement and Dispute Modified 4015 3011 0 Form and Instruction 22 Subject Statement and Dispute.pdf
Title IV Clinical Privileges Actions Modified 782 587 0 Form and Instruction 7 Title IV Clinical Privileges Actions.pdf
Total burden requested under this ICR: 8114604 374258 0  
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