Authorized Agent Designation

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: Regulations and Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Document Name Document Type
Form 29 Authorized Agent Designation Form and Instruction
29 Authorized Agent Designation 29 AuthorizedAgentDesignation.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Authorized Agent Designation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	29	Authorized Agent Designation	29 AuthorizedAgentDesignation.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 788	Number of Respondents for Small Entity: 10

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	788	788
Annual IC Time Burden (Hours)	197	197
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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