Information Collection

Information Collection Requirements in Final Peer Review Organizations Sanction Regulations 42 CFR Sections 1004.40, 1004.50, 1004.60, 1004.70

IC 8053 under ICR 202102-0938-004 · OMB 0938-0444.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0444 can be found here:

2024-12-23 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-65 Information Collection Requirements in Final Peer Review Organizations Sanction Regulations 42 CFR Sections 1004.40, 1004.50, 1004.50, 1004.60, 1004.70	Form and Instruction
CMS-R-65 Sanctions Template Letter Sanctions Template Letter_11232020_CMS-R-65Final.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Information Collection Requirements in Final Peer Review Organizations Sanction Regulations 42 CFR Sections 1004.40, 1004.50, 1004.50, 1004.60, 1004.70

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 1004.40 42 CFR 1004.50 42 CFR 1004.60 42 CFR 1004.70

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-65	Sanctions Template Letter	Sanctions Template Letter_11232020_CMS-R-65Final.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	4,716	4,716
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.