Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Account Balance Transfer Removed 0 0 0 Form and Instruction 39
Account Discrepancy Modified 19 5 0 Form and Instruction 35
Accreditation Modified 10 8 0 Form and Instruction 6
Agent Registration (Initial) Modified 107 107 0 Form and Instruction 31
Agent Registration (Renewal & Update) Modified 380 31 0 Form and Instruction 32
Authorized Agent Attestation Modified 167 42 0 Form and Instruction 26
Authorized Agent Designation Modified 193 193 0 Form and Instruction 34
Civil Judgment Modified 10 8 0 Form and Instruction 13
Continuous Query Modified 3095091 105751 7737728 Form and Instruction 21
Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal Modified 25295 2281 0 Form and Instruction 1
Corrective Action Plan (Entity) Modified 10 1 0 Form and Instruction 29
Criminal Conviction (Guilty Plea or Trial) Modified 1289 784 0 Form and Instruction 9
DEA/Federal Licensure Modified 674 506 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 632 51 0 Form and Instruction 33
Entity Registration (Initial) Modified 4176 4176 0 Form and Instruction 24
Entity Registration (Renewal & Update) Modified 15020 3755 0 Form and Instruction 25
Exclusion/Debarment Modified 5015 1094 0 Form and Instruction 14
Government Administrative Modified 2481 595 0 Form and Instruction 15
Health Center Attestation Modified 781 781 0 Form and Instruction 41
Health Plan Action Modified 445 334 0 Form and Instruction 16
Hospital Attestation Modified 3293 3293 0 Form and Instruction 42
Injunction Modified 2 2 0 Form and Instruction 12
Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation Modified 260 260 0 Form and Instruction 43
Medical Malpractice Payment Modified 11934 8425 0 Form and Instruction 2
Missing Report from Query Form Modified 10 1 0 Form and Instruction 40
New Administrator Request Modified 191 16 0 Form and Instruction 36
Nolo Contendere (no contest) plea Modified 34 26 0 Form and Instruction 11
One Time Query for an Individual Modified 5624382 127953 14060955 Form and Instruction 17
One Time Query for an Organization Modified 127617 6714 319043 Form and Instruction 18
Other Eligible Entity Attestation Modified 5349 5349 0 Form and Instruction 44
Peer Review Organization Modified 10 8 0 Form and Instruction 5
Professional Society Modified 24 18 0 Form and Instruction 8
Purchase Query Credits Modified 7282 583 18205 Form and Instruction 37
Reconciling Missing Actions Modified 1924 154 0 Form and Instruction 30
Request for Dispute Resolution Modified 117 936 0 Form and Instruction 23
Self-Query on an Individual Modified 266839 112073 800517 Form and Instruction 19
Self-Query on an Organization Modified 665 280 1995 Form and Instruction 20
State Licensing Board Attestation Modified 346 346 0 Form and Instruction 28
State Licensing Board Data Request Modified 51 536 0 Form and Instruction 27
State Licensure Modified 32044 12461 0 Form and Instruction 3
Subject Statement and Dispute Modified 3453 2590 0 Form and Instruction 22
Title IV Clinical Privileges Actions Modified 827 621 0 Form and Instruction 7
Total burden requested under this ICR: 9238519 403194 22938443  
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