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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Document Name Document Type
Form 23 Request for Dispute Resolution Form and Instruction
23 Request for Dispute Resolution_0915-0126.pdf Request for Dispute Resolution_0915-0126.pdf Form and Instruction
23 Request for Dispute Resolution_0915-0126.pdf Request for Dispute Resolution_0915-0126.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Request for Dispute Resolution	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	23	Request for Dispute Resolution_0915-0126.pdf	Request for Dispute Resolution_0915-0126.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 74	Number of Respondents for Small Entity: 74

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	74	-25	99
Annual IC Time Burden (Hours)	592	-200	792
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.