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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.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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