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 Review and Dispute Form and Instruction New Repair queued
Form CMS-10495 Review and Dispute Form and Instruction New Available
Form CMS-10495 Attestation and Assumptions Form and Instruction New Available
Form CMS-10495 Attestation and Assumptions Form and Instruction New Available
Form CMS-10495 General Research Ownership Form and Instruction New Available
Form CMS-10495 Registration Form and Instruction 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 Repair queued
Form CMS-10495 Attestation Form and Instruction Modified Available
Form CMS-10495 General Research Ownership Form and Instruction Modified Repair queued
Form CMS-10495 Teaching Hospitals Registration Form and Instruction Modified Available
Form CMS-10495 General Research Ownership Form and Instruction Modified Available
Form CMS-10495 Physician Registration Form and Instruction Modified Available
Form CMS-10495 Registration – Physicians & Teaching Hospitals, Applicable Manufacturers and Group Purchasing Organizations Form and Instruction Modified Available
Form CMS-10495 General Research Ownership 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 NewReview and Dispute
237513 AM Dispute Resolution and Correction Form and Instruction NewReview and Dispute
237511 Applicable GPO (Assumptions Document) Form and Instruction NewAttestation and Assumptions
237407 Applicable GPO (Attestation) Form and Instruction NewAttestation and Assumptions
237406 Applicable GPO (Record Retention) Instruction New
237405 Applicable GPO (Registration) Form and Instruction NewGeneral Research Ownership
237405 Applicable GPO (Registration) Form and Instruction NewRegistration
230225 AM (Data collection and submission) Instruction Modified
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 (Assumptions Document) Form and Instruction ModifiedAssumptions
211455 AM (Attestation) Form and Instruction ModifiedAttestation
211454 AM (Record Retention) Instruction Modified
209365 Teaching Hospitals (Registration) Form and Instruction ModifiedGeneral Research Ownership
209365 Teaching Hospitals (Registration) Form and Instruction ModifiedTeaching Hospitals Registration
209364 Physicians (Registration) Form and Instruction ModifiedGeneral Research Ownership
209364 Physicians (Registration) Form and Instruction ModifiedPhysician Registration
209363 AM (Registration) Form and Instruction ModifiedRegistration – Physicians & Teaching Hospitals, Applicable Manufacturers and Group Purchasing Organizations
209363 AM (Registration) Form and Instruction ModifiedGeneral Research Ownership

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
18
table that charts list of burden
IC Title Form No. Form Name
AM (Assumptions Document) CMS-10495
AM (Attestation) CMS-10495
AM (Data collection and submission)
AM (Record Retention)
AM (Registration) CMS-10495, CMS-10495 ,  
AM Dispute Resolution and Correction CMS-10495
Applicable GPO (Assumptions Document) CMS-10495
Applicable GPO (Attestation) CMS-10495
Applicable GPO (Data collection and submission)
Applicable GPO (Record Retention)
Applicable GPO (Registration) CMS-10495, CMS-10495 ,  
Applicable GPO Dispute and Resolution Correction CMS-10495
Dispute Resolution and Correction (Physicians) CMS-10495
Dispute and Resolution Correction (Teaching Hospitals) CMS-10495
Modifying Nature of Payment Categories
Physicians (Registration) CMS-10495, CMS-10495 ,  
Standardizing Data on Reported Products
Teaching Hospitals (Registration) CMS-10495, CMS-10495 ,  



Reginfo record details
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