Information Collection Request

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

ICR 201907-0938-008 · OMB 0938-1237 · Historical Inactive

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10495 Applicable GPO Dispute and Resolution Correction Form and Instruction New Repair queued
Form CMS-10495 AM Dispute Resolution and Correction Form and Instruction New Available
Form CMS-10495 Applicable GPO (Assumptions Document) Form and Instruction New Available
Form CMS-10495 Applicable GPO (Attestation) Form and Instruction New Available
Form CMS-10495 Applicable GPO (Registration) Form and Instruction New Available
Form CMS-10495 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction Modified Available
Form CMS-10495 Dispute Resolution and Correction (Physicians) Form and Instruction Modified Available
Form CMS-10495 AM (Assumptions Document) Form and Instruction Modified Repair queued
Form CMS-10495 AM (Attestation) Form and Instruction Modified Available
Form CMS-10495 Teaching Hospitals (Registration) Form and Instruction Modified Available
Form CMS-10495 Physicians (Registration) Form and Instruction Modified Available
Form CMS-10495 AM (Registration) Form and Instruction Modified Available
CMS-10495 - Supporting Statement A (NPRM version 7).docx Supporting Statement A Uploaded 2019-08-26 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
237521 Standardizing Data on Reported Products New
237520 Modifying Nature of Payment Categories New
237519 Applicable GPO (Data collection and submission) Instruction New
237516 Applicable GPO Dispute and Resolution Correction Form and Instruction New
237513 AM Dispute Resolution and Correction Form and Instruction New
237511 Applicable GPO (Assumptions Document) Form and Instruction New
237407 Applicable GPO (Attestation) Form and Instruction New
237406 Applicable GPO (Record Retention) Instruction New
237405 Applicable GPO (Registration) Form and Instruction New
230225 AM (Data collection and submission) Instruction Modified
212217 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction Modified
212216 Dispute Resolution and Correction (Physicians) Form and Instruction Modified
211456 AM (Assumptions Document) Form and Instruction Modified
211455 AM (Attestation) Form and Instruction Modified
211454 AM (Record Retention) Instruction Modified
209365 Teaching Hospitals (Registration) Form and Instruction Modified
209364 Physicians (Registration) Form and Instruction Modified
209363 AM (Registration) Form and Instruction Modified

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 03/31/2021
179,048 0 179,048
1,143,241 0 1,143,241
0 0 0







Reginfo record details
  No