Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
HospitalRegistrationRenewal New 3198 800 0 Form and Instruction 32
Account Discrepancy Modified 41 10 0 Form and Instruction 30
Accreditation Modified 12 9 0 Form and Instruction 6
Agent Registration (Initial) Modified 37 37 0 Form and Instruction 26
Agent Registration (Renewal & Update) Modified 3198 800 0 Form and Instruction 27
Authorized Agent Designation Modified 788 197 0 Form and Instruction 29
Civil Judgment Modified 14 11 0 Form and Instruction 13
Continuous Query Modified 629921 40693 0 Form and Instruction 21
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 37667 5126 0 Form and Instruction 1
Corrective Action Plan (Entity) New 10 1 0 Form and Instruction 36
Criminal Conviction (Guilty Plea or Trial) Modified 2245 981 0 Form and Instruction 9
DEA/Federal Licensure Modified 114 86 0 Form and Instruction 4
Deferred Conviction or Pre-Trial Diversion Modified 50 38 0 Form and Instruction 10
Electronic Transfer of Funds (ETF) Authorization Modified 566 45 0 Form and Instruction 28
Entity Registration (Initial) Modified 524 524 0 Form and Instruction 24
Entity Registration (Renewal & Update) Modified 6383 1596 0 Form and Instruction 25
Exclusion/Debarment Modified 6279 891 0 Form and Instruction 14
Government Administrative Modified 2233 1675 0 Form and Instruction 15
Health Plan Action Modified 524 393 0 Form and Instruction 16
HospitalRegistrationInitial New 37 37 0 Form and Instruction 31
Injunction Modified 10 8 0 Form and Instruction 12
LicensingBoardAttestation New 354 354 0 Form and Instruction 35
LicensingBoardDataRequest New 140 1470 0 Form and Instruction 33
Medical Malpractice Payment Modified 12863 9460 0 Form and Instruction 2
Nolo Contendere (no contest) plea Modified 80 60 0 Form and Instruction 11
One Time Query for an Individual Modified 4144033 159115 0 Form and Instruction 17
One Time Query for an Organization Modified 42186 3195 0 Form and Instruction 18
Peer Review Organization Modified 10 8 0 Form and Instruction 5
Professional Society Modified 50 38 0 Form and Instruction 8
ReconcilingMissingActionForm New 2176 174 0 Form and Instruction 37
ReportingDiscrepancyLetter New 389 1556 0 Form and Instruction 34
Request for Secretarial Review Modified 94 752 0 Form and Instruction 23
Self-Query on an Individual Modified 77318 32474 0 Form and Instruction 19
Self-Query on an Organization Modified 427 427 0 Form and Instruction 20
State Licensure Modified 34192 12583 0 Form and Instruction 3
Subject Statement and Dispute Modified 3501 2626 0 Form and Instruction 22
Title IV Clinical Privileges Actions Modified 671 503 0 Form and Instruction 7
Total burden requested under this ICR: 5012335 278753 0  
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