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 4 1 0 Form and Instruction 35
Accreditation Modified 10 8 0 Form and Instruction 6
Agent Registration (Initial) Modified 78 78 0 Form and Instruction 31
Agent Registration (Renewal & Update) Modified 318 25 0 Form and Instruction 32
Authorized Agent Attestation Modified 171 171 0 Form and Instruction 26
Authorized Agent Designation Modified 183 46 0 Form and Instruction 34
Civil Judgment Modified 6 5 0 Form and Instruction 13
Continuous Query Modified 1931578 82745 0 Form and Instruction 21
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 23879 2230 0 Form and Instruction 1
Corrective Action Plan (Entity) Modified 10 1 0 Form and Instruction 29
Criminal Conviction (Guilty Plea or Trial) Modified 1385 736 0 Form and Instruction 9
DEA/Federal Licensure Modified 555 416 0 Form and Instruction 4
Deferred Conviction or Pre-Trial Diversion Modified 60 45 0 Form and Instruction 10
Education Request Modified 10 1 0 Form and Instruction 38
Electronic Transfer of Funds (EFT) Authorization Modified 734 59 0 Form and Instruction 33
Entity Registration (Initial) Modified 3252 3252 0 Form and Instruction 24
Entity Registration (Renewal & Update) Modified 12990 3248 0 Form and Instruction 25
Exclusion/Debarment Modified 3897 967 0 Form and Instruction 14
Government Administrative Modified 1999 1027 0 Form and Instruction 15
Health Center Attestation Modified 724 724 0 Form and Instruction 41
Health Plan Action Modified 391 293 0 Form and Instruction 16
Hospital Attestation Modified 3238 3238 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 Modified 267 267 0 Form and Instruction 43
Medical Malpractice Payment Modified 11527 8311 0 Form and Instruction 2
Missing Report from Query Form Modified 10 1 0 Form and Instruction 40
New Administrator Request Modified 215 17 0 Form and Instruction 36
Nolo Contendere (no contest) plea Modified 75 56 0 Form and Instruction 11
One Time Query for an Individual Modified 5735715 144413 0 Form and Instruction 17
One Time Query for an Organization Modified 111088 6179 0 Form and Instruction 18
Other Eligible Entity Attestation Modified 4790 4790 0 Form and Instruction 44
Peer Review Organization Modified 10 8 0 Form and Instruction 5
Professional Society Modified 27 20 0 Form and Instruction 8
Purchase Query Credits Modified 5590 447 0 Form and Instruction 37
Reconciling Missing Actions Modified 1371 110 0 Form and Instruction 30
Request for Dispute Resolution Modified 83 664 0 Form and Instruction 23
Self-Query on an Individual Modified 223589 93907 0 Form and Instruction 19
Self-Query on an Organization Modified 879 369 0 Form and Instruction 20
State Licensing Board Attestation Modified 360 360 0 Form and Instruction 28
State Licensing Board Data Request Modified 87 914 0 Form and Instruction 27
State Licensure Modified 28632 10502 0 Form and Instruction 3
Subject Statement and Dispute Modified 4015 3011 0 Form and Instruction 22
Title IV Clinical Privileges Actions Modified 782 587 0 Form and Instruction 7
Total burden requested under this ICR: 8114604 374258 0  
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