Form 23 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

Request for Dispute Resolution

OMB: 0915-0126

⚠️ Notice: This form may be outdated.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

2023-11-09 - Revision of a currently approved collection
2021-01-25 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

State Changes
Label
Public Burden
Statement

PDF Name
Request for
Dispute Resolution

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	2017-09-27