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 Discrepancy Modified 85 21 0 Form and Instruction 35
Accreditation Modified 10 8 0 Form and Instruction 6
Agent Registration (Initial) Modified 44 44 0 Form and Instruction 31
Agent Registration (Renewal & Update) Modified 304 24 0 Form and Instruction 32
Authorized Agent Attestation Modified 350 350 0 Form and Instruction 26
Authorized Agent Designation Modified 183 46 0 Form and Instruction 34
Civil Judgment Modified 9 7 0 Form and Instruction 13
Continuous Query Modified 1425972 64744 0 Form and Instruction 21
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 30219 2985 0 Form and Instruction 1
Corrective Action Plan (Entity) Modified 10 1 0 Form and Instruction 29
Criminal Conviction (Guilty Plea or Trial) Modified 1857 882 0 Form and Instruction 9
DEA/Federal Licensure Modified 600 450 0 Form and Instruction 4
Deferred Conviction or Pre-Trial Diversion Modified 70 53 0 Form and Instruction 10
Education Request Modified 40 3 0 Form and Instruction 38
Electronic Transfer of Funds (EFT) Authorization Modified 644 52 0 Form and Instruction 33
Entity Registration (Initial) Modified 3484 3484 0 Form and Instruction 24
Entity Registration (Renewal & Update) Modified 13245 3311 0 Form and Instruction 25
Exclusion/Debarment Modified 4213 1281 0 Form and Instruction 14
Government Administrative Modified 1789 1314 0 Form and Instruction 15
Health Center Attestation New 722 722 0 Form and Instruction 41
Health Plan Action Modified 488 366 0 Form and Instruction 16
Hospital Attestation New 3416 3416 0 Form and Instruction 42
Injunction Modified 10 8 0 Form and Instruction 12
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation New 274 274 0 Form and Instruction 43
Medical Malpractice Payment Modified 11777 8612 0 Form and Instruction 2
Missing Report from Query Form Modified 10 1 0 Form and Instruction 40
New Administrator Request Modified 600 48 0 Form and Instruction 36
Nolo Contendere (no contest) plea Modified 127 95 0 Form and Instruction 11
One Time Query for an Individual Modified 5307954 157659 0 Form and Instruction 17
One Time Query for an Organization Modified 76291 4062 0 Form and Instruction 18
Other Eligible Entity Attestation New 1884 1884 0 Form and Instruction 44
Peer Review Organization Modified 10 8 0 Form and Instruction 5
Professional Society Modified 41 31 0 Form and Instruction 8
Purchase Query Credits Modified 1786 143 0 Form and Instruction 37
Reconciling Missing Actions Modified 1491 1193 0 Form and Instruction 30
Request for Dispute Resolution Modified 74 592 0 Form and Instruction 23
Self-Query on an Individual Modified 168557 70794 0 Form and Instruction 19
Self-Query on an Organization Modified 1059 445 0 Form and Instruction 20
State Licensing Board Attestation Modified 325 325 0 Form and Instruction 28
State Licensing Board Data Request Modified 60 630 0 Form and Instruction 27
State Licensure Modified 36938 14817 0 Form and Instruction 3
Subject Statement and Dispute Modified 3264 2448 0 Form and Instruction 22
Title IV Clinical Privileges Actions Modified 978 734 0 Form and Instruction 7
Total burden requested under this ICR: 7101274 348368 0  
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