Information Collection Request

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

ICR 202107-0938-014 · OMB 0938-1237 · Historical Inactive

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10495 User Guide for Reporting Entities Form and Instruction New Available
Form CMS-10495 Remove General Ownership Records: AM and Applicable GPO Data Collection and Submission Form and Instruction New Repair queued
Form CMS-10495 User Guide for Reporting Entities Form and Instruction New Available
Form CMS-10495 Disallowing Record Deletion Without Reason: AM and Applicable GPO Data Collection and Submission Form and Instruction New Repair queued
Form CMS-10495 Dispute Resolution and Correction Form New Available
Form CMS-10495 Teaching Hospital Contact Field: Dispute Resolution and Correction (Teaching Hospitals) Form New Repair queued
Form CMS-10495 Attestation and Assumptions Form New Available
Form CMS-10495 Updated Contact Information: AM and Applicable GPO Attestations Form New Repair queued
Form CMS-10495 Attestation and Assumptions Form New Available
Form CMS-10495 Optional Annual Recertification: AM and Applicable GPO Attestations Form New Repair queued
Form CMS-10495 General-Research-Ownership Submission Data Elements Screen Shots Form and Instruction Unchanged Repair queued
Form CMS-10495 Open Payments User Guide Form and Instruction Unchanged Available
Form CMS-10495 Applicable GPO (Data Collection and Submission) Form and Instruction Unchanged Repair queued
Form CMS-10495 Review and Dispute Email Notifications Form and Instruction Unchanged Repair queued
Form CMS-10495 Review and Dispute Screen Shots Form and Instruction Unchanged Available
Form CMS-10495 GPO Dispute and Resolution Correction Form and Instruction Unchanged Repair queued
Form CMS-10495 Review and Dispute Email Notifications Form and Instruction Unchanged Available
Form CMS-10495 Review and Dispute Screen Shots Form and Instruction Unchanged Repair queued
Form CMS-10495 Dispute Resolution and Correction (AM) Form and Instruction Unchanged Repair queued
Form CMS-10495 Assumptions Form and Instruction Unchanged Repair queued
Form CMS-10495 Applicable GPO (Assumptions Document) Form and Instruction Unchanged Repair queued
Form CMS-10495 Attestation Form and Instruction Unchanged Available
Form CMS-10495 Applicable GPO (Attestation) Form and Instruction Unchanged Repair queued
Form CMS-10495 Registration Form and Instruction Unchanged Repair queued
Form CMS-10495 Applicable GPO (Registration) Form and Instruction Unchanged Repair queued
Form CMS-10495 General-Research-Ownership Submission Data Elements and Screen Shots Form and Instruction Unchanged Available
Form CMS-10495 Open Payments User Guide Form and Instruction Unchanged Available
Form CMS-10495 AM (Data Collection and Submission) Form and Instruction Unchanged Repair queued
Form CMS-10495 Review and Dispute Email Notifications Form and Instruction Modified Repair queued
Form CMS-10495 Review and Dispute Screen Shots Form and Instruction Modified Repair queued
Form CMS-10495 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction Modified Repair queued
Form CMS-10495 Review and Dispute Email Notifications Form and Instruction Unchanged Repair queued
Form CMS-10495 Review and Dispute Screen Shots Form and Instruction Unchanged Repair queued
Form CMS-10495 Dispute Resolution and Correction (Physicians) Form and Instruction Unchanged Repair queued
Form CMS-10495 Assumptions Form and Instruction Unchanged Repair queued
Form CMS-10495 AM (Assumptions Document) Form and Instruction Unchanged Repair queued
Form CMS-10495 Attestation Form and Instruction Unchanged Available
Form CMS-10495 AM (Attestation) Form and Instruction Unchanged Repair queued
Form CMS-10495 Registration Form and Instruction Unchanged Repair queued
Form CMS-10495 Teaching Hospitals (Registration) Form and Instruction Unchanged Repair queued
Form CMS-10495 Registration Form and Instruction Unchanged Available
Form CMS-10495 Physicians (Registration) Form and Instruction Unchanged Repair queued
Form CMS-10495 Registration Form and Instruction Unchanged Available
Form CMS-10495 AM (Registration) Form and Instruction Unchanged Repair queued
CMS-10495 - Supporting Statement A (CMS-1751-P version 5).docx Supporting Statement A Uploaded 2021-08-02 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
248593 Remove General Ownership Records: AM and Applicable GPO Data Collection and Submission Form and Instruction NewUser Guide for Reporting Entities
248593 Remove General Ownership Records: AM and Applicable GPO Data Collection and Submission Form and Instruction New
248591 Disallowing Record Deletion Without Reason: AM and Applicable GPO Data Collection and Submission Form and Instruction NewUser Guide for Reporting Entities
248591 Disallowing Record Deletion Without Reason: AM and Applicable GPO Data Collection and Submission Form and Instruction New
248590 Teaching Hospital Contact Field: Dispute Resolution and Correction (Teaching Hospitals) Form NewDispute Resolution and Correction
248590 Teaching Hospital Contact Field: Dispute Resolution and Correction (Teaching Hospitals) Form New
248584 Updated Contact Information: AM and Applicable GPO Attestations Form NewAttestation and Assumptions
248584 Updated Contact Information: AM and Applicable GPO Attestations Form New
248583 Optional Annual Recertification: AM and Applicable GPO Attestations Form NewAttestation and Assumptions
248583 Optional Annual Recertification: AM and Applicable GPO Attestations Form New
238594 Standardizing Data on Reported Products Unchanged
238593 Modifying Nature of Payment Categories Unchanged
238592 Applicable GPO (Data Collection and Submission) Form and Instruction UnchangedGeneral-Research-Ownership Submission Data Elements Screen Shots
238592 Applicable GPO (Data Collection and Submission) Form and Instruction UnchangedOpen Payments User Guide
238592 Applicable GPO (Data Collection and Submission) Form and Instruction Unchanged
238591 GPO Dispute and Resolution Correction Form and Instruction UnchangedReview and Dispute Email Notifications
238591 GPO Dispute and Resolution Correction Form and Instruction UnchangedReview and Dispute Screen Shots
238591 GPO Dispute and Resolution Correction Form and Instruction Unchanged
238590 Dispute Resolution and Correction (AM) Form and Instruction UnchangedReview and Dispute Email Notifications
238590 Dispute Resolution and Correction (AM) Form and Instruction UnchangedReview and Dispute Screen Shots
238590 Dispute Resolution and Correction (AM) Form and Instruction Unchanged
238589 Applicable GPO (Assumptions Document) Form and Instruction UnchangedAssumptions
238589 Applicable GPO (Assumptions Document) Form and Instruction Unchanged
238588 Applicable GPO (Attestation) Form and Instruction UnchangedAttestation
238588 Applicable GPO (Attestation) Form and Instruction Unchanged
238587 Applicable GPO (Record Retention) Instruction Unchanged
238586 Applicable GPO (Registration) Form and Instruction UnchangedRegistration
238586 Applicable GPO (Registration) Form and Instruction Unchanged
230225 AM (Data Collection and Submission) Form and Instruction UnchangedGeneral-Research-Ownership Submission Data Elements and Screen Shots
230225 AM (Data Collection and Submission) Form and Instruction UnchangedOpen Payments User Guide
230225 AM (Data Collection and Submission) Form and Instruction Unchanged
212217 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction ModifiedReview and Dispute Email Notifications
212217 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction ModifiedReview and Dispute Screen Shots
212217 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction Modified
212216 Dispute Resolution and Correction (Physicians) Form and Instruction UnchangedReview and Dispute Email Notifications
212216 Dispute Resolution and Correction (Physicians) Form and Instruction UnchangedReview and Dispute Screen Shots
212216 Dispute Resolution and Correction (Physicians) Form and Instruction Unchanged
211456 AM (Assumptions Document) Form and Instruction UnchangedAssumptions
211456 AM (Assumptions Document) Form and Instruction Unchanged
211455 AM (Attestation) Form and Instruction UnchangedAttestation
211455 AM (Attestation) Form and Instruction Unchanged
211454 AM (Record Retention) Instruction Unchanged
209365 Teaching Hospitals (Registration) Form and Instruction UnchangedRegistration
209365 Teaching Hospitals (Registration) Form and Instruction Unchanged
209364 Physicians (Registration) Form and Instruction UnchangedRegistration
209364 Physicians (Registration) Form and Instruction Unchanged
209363 AM (Registration) Form and Instruction UnchangedRegistration
209363 AM (Registration) Form and Instruction Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
07/31/2024 36 Months From Approved 07/31/2024
78,812 0 78,812
1,897,790 0 1,897,790
0 0 0





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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) CMS-10495, CMS-10495 ,  
AM (Record Retention)
AM (Registration) CMS-10495
Applicable GPO (Assumptions Document) CMS-10495
Applicable GPO (Attestation) CMS-10495
Applicable GPO (Data Collection and Submission) CMS-10495, CMS-10495 ,  
Applicable GPO (Record Retention)
Applicable GPO (Registration) CMS-10495
Disallowing Record Deletion Without Reason: AM and Applicable GPO Data Collection and Submission CMS-10495
Dispute Resolution and Correction (AM) CMS-10495, CMS-10495 ,  
Dispute Resolution and Correction (Physicians) CMS-10495, CMS-10495 ,  
Dispute and Resolution Correction (Teaching Hospitals) CMS-10495, CMS-10495 ,  
GPO Dispute and Resolution Correction CMS-10495, CMS-10495 ,  
Modifying Nature of Payment Categories
Optional Annual Recertification: AM and Applicable GPO Attestations CMS-10495
Physicians (Registration) CMS-10495
Remove General Ownership Records: AM and Applicable GPO Data Collection and Submission CMS-10495
Standardizing Data on Reported Products
Teaching Hospital Contact Field: Dispute Resolution and Correction (Teaching Hospitals) CMS-10495
Teaching Hospitals (Registration) CMS-10495
Updated Contact Information: AM and Applicable GPO Attestations CMS-10495



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