Request for Dispute Resolution

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

OMB: 0906-0081

IC ID: 206502

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Request for Dispute Resolution
 
No Modified
 
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 23 Request for Dispute Resolution.pdf Request for Dispute Resolution.pdf Yes Yes Fillable Fileable

Health Consumer Health and Safety

System of Record Notice 09-15-0054  88 FR 17854

83 0
   
Individuals or Households
 
   100 %

  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 83 0 9 0 0 74
Annual IC Time Burden (Hours) 664 0 72 0 0 592
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.

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