Information Collection

Patient-Provider Selected Dispute Resolution Entity Recertification

IC 249552 under ICR 202109-0938-015 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10791 - 5. HHS - Appendix SDR Entity Certification Data Elements_508c.pdf	Other-Data Elements

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.620

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
Other-Data Elements			CMS-10791 - 5. HHS - Appendix SDR Entity Certification Data Elements_508c.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	257	257

Documents for IC

table that charts IC Documents
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.