Information Collection

Medical Privileges Request Form

IC 46245 under ICR 201306-0917-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 0917-0009-4 Medical Privileges Request Form	Form and Instruction
0917-0009-4 0917-0009-4, Medical Privileges Request Form Medical_privileges_request_form[1].doc	Form and Instruction

IC Title:

Medical Privileges Request Form

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:

table that charts list of instruments
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

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	325	325
Annual IC Time Burden (Hours)	325	325
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.