Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Account Discrepancy New 20 5 0 Form and Instruction 30
Accreditation New 10 8 0 Form and Instruction 6
Agent Registration (Initial) New 100 25 0 Form and Instruction 26
Agent Registration (Renewal & Update) New 100 25 0 Form and Instruction 27
Authorized Agent Designation New 1290 323 0 Form and Instruction 29
Civil Judgment New 10 8 0 Form and Instruction 13
Continuous Query New 387767 31021 0 Form and Instruction 21
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal New 38785 9696 0 Form and Instruction 1
Criminal Conviction (Guilty Plea or Trial) New 1023 767 0 Form and Instruction 9
DEA/Federal Licensure New 499 374 0 Form and Instruction 4
Deferred Conviction or Pre-Trial Diversion New 126 95 0 Form and Instruction 10
Electronic Transfer of Funds (ETF) Authorization New 562 141 0 Form and Instruction 28
Entity Registration (Initial) New 35915 35915 0 Form and Instruction 24
Entity Registration (Renewal & Update) New 15461 1237 0 Form and Instruction 25
Exclusion/Debarment New 2402 1802 0 Form and Instruction 14
Government Administrative New 2682 2012 0 Form and Instruction 15
Health Plan Action New 561 421 0 Form and Instruction 16
Injunction New 10 8 0 Form and Instruction 12
Medical Malpractice Payment New 14193 10645 0 Form and Instruction 2
National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Pract Removed 0 0 0 Form and Instruction NPDB Identity Proofing Forms
Form 0915-0126 NPDB Forms
Nolo Contendere (no contest) plea New 63 47 0 Form and Instruction 11
One Time Query for an Individual New 986552 78924 0 Form and Instruction 17
One Time Query for an Organization New 18892 1511 0 Form and Instruction 18
Peer Review Organization New 10 8 0 Form and Instruction 5
Professional Society New 71 53 0 Form and Instruction 8
Request for Secretarial Review New 83 664 0 Form and Instruction 23
Section 1921 forms Removed 0 0 0 Form and Instruction 2
Form and Instruction 1
Form and Instruction 3
Self-Query on an Individual New 154824 65026 0 Form and Instruction 19
Self-Query on an Organization New 1095 460 0 Form and Instruction 20
State Licensure New 28700 21525 0 Form and Instruction 3
Subject Statement and Dispute New 3347 2510 0 Form and Instruction 22
Title IV Clinical Privileges Actions New 962 722 0 Form and Instruction 7
Total burden requested under this ICR: 1696115 265978 0  
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