Request for Dispute Resolution Form and Instruction
State Changes
Label
OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy
PDF Name
Item Type
Request for
Modal
Dispute Resolution
Trigger
When the user selects the link the modal is displayed
with the public burden statement content.
| File Type | application/pdf |
| File Title | Request for Dispute Resolution |
| Subject | NPDB dispute |
| Author | Health Resources and Services Administration |
| File Modified | 2023-05-22 |
| File Created | 2023-01-18 |