Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Account Balance Transfer New 10 1 0 Form and Instruction 39
Account Discrepancy Modified 10 3 0 Form and Instruction 35
Accreditation Modified 10 8 0 Form and Instruction 6
Agent Registration (Initial) Modified 85 85 0 Form and Instruction 31
Agent Registration (Renewal) Modified 278 23 0 Form and Instruction 32
Authorized Agent Designation Modified 213 54 0 Form and Instruction 34
Civil Judgment Modified 10 8 0 Form and Instruction 13
Continuous Query Modified 870698 51578 0 Form and Instruction 21
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 29080 2785 0 Form and Instruction 1
Corrective Action Plan Modified 10 1 0 Form and Instruction 29
Criminal Conviction (Guilty Plea or Trial) Modified 1828 856 0 Form and Instruction 9
DEA/Federal Licensure Modified 698 524 0 Form and Instruction 4
Deferred Conviction or Pre-Trial Diversion Modified 54 41 0 Form and Instruction 10
Educational Request New 10 1 0 Form and Instruction 38
Electronic Transfer of Funds (EFT) Authorization Modified 654 53 0 Form and Instruction 33
Entity Profile Modified 9000 2250 0 Form and Instruction 26
Entity Registration (Initial) Modified 1073 1073 0 Form and Instruction 24
Entity Registration (Renewal & Update) Modified 14060 3515 0 Form and Instruction 25
Exclusion/Debarment Modified 4804 1219 0 Form and Instruction 14
Government Administrative Modified 2062 1547 0 Form and Instruction 15
Health Plan Action Modified 335 252 0 Form and Instruction 16
Injunction Modified 10 8 0 Form and Instruction 12
Licensing Board Attestation Modified 301 301 0 Form and Instruction 28
Licensing Board Data Request Modified 146 1533 0 Form and Instruction 27
Medical Malpractice Payment Modified 12235 8996 0 Form and Instruction 2
Missing Report Form New 29 3 0 Form and Instruction 40
New Administrator Request Modified 3016 242 0 Form and Instruction 36
Nolo Contendere (no contest) plea Modified 85 64 0 Form and Instruction 11
One Time Query for an Individual Modified 4867722 165195 0 Form and Instruction 17
One Time Query for an Organization Modified 49896 3180 0 Form and Instruction 18
Peer Review Organization Modified 10 8 0 Form and Instruction 5
Professional Society Modified 49 37 0 Form and Instruction 8
Query Credit Purchase Modified 789 64 0 Form and Instruction 37
Reconciling Missing Actions Modified 7981 6385 0 Form and Instruction 30
Request for Dispute Resolution Modified 99 792 0 Form and Instruction 23
Self-Query on an Individual Modified 131481 55223 0 Form and Instruction 19
Self-Query on an Organization Modified 1545 649 0 Form and Instruction 20
State Licensure Modified 45140 14378 0 Form and Instruction 3
Subject Statement and Dispute Modified 3547 2661 0 Form and Instruction 22
Title IV Clinical Privileges Actions Modified 698 524 0 Form and Instruction 7
Total burden requested under this ICR: 6059761 326120 0  
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