Information Collection Request

Registration, Attestation, Dispute Resolution and Correction, Assumptions Document and Data Retention Requirements for Open Payments (CMS-10495)

ICR 201707-0938-018 · OMB 0938-1237 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10495 Open Payments User Guide - Data Submission Form New Available
Form CMS-10495 Dispute Resolution and Correction Form and Instruction Modified Available
Form CMS-10495 Dispute Resolution and Correction Form and Instruction Modified Available
Form CMS-10495 Assumptions Form and Instruction Modified Available
Form CMS-10495 Attestation Form and Instruction Modified Repair queued
Form CMS-10495 Teaching Hospitals Registration Form and Instruction Modified Available
Form CMS-10495 Physician Registration Form and Instruction Modified Repair queued
Form CMS-10495 AM and AGPO Registration Form and Instruction Modified Available
CMS-10495 - 2016-Data-Submission-Data-Mapping-Doc.xlsx Supplementary Document Uploaded 2018-01-11 Available
CMS-10495 - Open-Payments-User-Guide 2018.pdf Supplementary Document Uploaded 2018-01-11 Available
CMS-10495 - Supporting Statement AFinal.docx Supporting Statement A Uploaded 2018-03-20 Available
Comment Response.docx Supplementary Document Uploaded 2017-07-31 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
230225 AM and Applicable GPO (Data submission) Form NewOpen Payments User Guide - Data Submission
212217 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction ModifiedDispute Resolution and Correction
212216 Dispute Resolution and Correction (Physicians) Form and Instruction ModifiedDispute Resolution and Correction
211456 AM and Applicable GPO (Assumptions Document) Form and Instruction ModifiedAssumptions
211455 AM and Applicable GPO (Attestation) Form and Instruction ModifiedAttestation
211454 AM and Applicable GPO (Record Retention) Instruction Modified
209365 Teaching Hospitals (Registration) Form and Instruction ModifiedTeaching Hospitals Registration
209364 Physicians (Registration) Form and Instruction ModifiedPhysician Registration
209363 AM and Applicable GPO (Registration) Form and Instruction ModifiedAM and AGPO Registration

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
03/31/2021 36 Months From Approved 03/31/2018
179,048 0 457,454
1,143,241 0 3,099,297
0 0 0





Reginfo record details
9
table that charts list of burden
IC Title Form No. Form Name
AM and Applicable GPO (Assumptions Document) CMS-10495
AM and Applicable GPO (Attestation) CMS-10495
AM and Applicable GPO (Data submission) CMS-10495
AM and Applicable GPO (Record Retention)
AM and Applicable GPO (Registration) CMS-10495
Dispute Resolution and Correction (Physicians) CMS-10495
Dispute and Resolution Correction (Teaching Hospitals) CMS-10495
Physicians (Registration) CMS-10495
Teaching Hospitals (Registration) CMS-10495

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 179,048 457,454 0 0 -278,406 0
Annual Time Burden (Hours) 1,143,241 3,099,297 0 0 -1,956,056 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No