Form 1 Correction, Revision to Action, Void, Notice of Appeal.p

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

Correction, Revision to Action, Void, Notice of Appeal

Correction, Revision to Action, Correction of Revision to Action, Void, Action on Appeal

OMB: 0915-0126

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0126 can be found here:

Document [pdf]

Download: pdf | pdf

Hidden Fields
For Correction, Revision to Action and Correction of Revision to Action, the hidden fields
will be the same the hidden fields for the initial report.
State Changes
For Correction, Revision to Action and Correction of Revision to Action, the state changes
will be the same the state changes for the initial report.
Label
Public Burden
Statement

PDF Name
Correction,
Revision to Action,
Correction of
Revision to Action,
Void, Action on
Appeal

Item Type
Modal

Trigger
When the user selects the Public Burden Statement
link the modal is displayed.

File Type	application/pdf
File Modified	2017-11-09
File Created	2017-09-12