Information Collection

Internal Medicine/Family Practice Privilege

IC 46245 under ICR 201004-0917-003 · OMB 0917-0009.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0009 can be found here:

Documents and Forms

Document Name Document Type
Internal Medicine/Family Practice Privilege Form
Medical Privileges Request Form Medical privileges request form.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Internal Medicine/Family Practice Privilege	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	NA	Medical Privileges Request Form	Medical privileges request form.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Report of Modified or Altered Systems Medical Staff Credentials and Privileges Record	FR Citation: 71 FR 16320

Number of Respondents: 325	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	325	-62	387
Annual IC Time Burden (Hours)	325	-62	387
Annual IC Cost Burden (Dollars)	0	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.