View Information Collection (IC)

View Information Collection (IC)

Medical Privileges Request Form
No Unchanged
Required to Obtain or Retain Benefits

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0917-0009-4 0917-0009-4, Medical Privileges Request Form Medical_privileges_request_form[1].doc No No Paper Only

Health Public Health Monitoring

Report of Modified or Altered Systems Medical Staff Credentials and Privileges Record  71 FR 16320

325 0
Individuals or Households
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 325 0 0 0 0 325
Annual IC Time Burden (Hours) 325 0 0 0 0 325
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.