Information Collection Request

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

ICR 202112-0938-008 · OMB 0938-1237 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10495 General-Research-Ownership Submission Data Elements Screen Shots Form and Instruction Modified Repair queued
Form CMS-10495 Open Payments User Guide Form and Instruction Modified Repair queued
Form CMS-10495 Applicable GPO (Data Collection and Submission) Form and Instruction Modified 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 GPO Dispute and Resolution Correction Form and Instruction Modified 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 Resolution and Correction (AM) Form and Instruction Modified 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 Modified Repair queued
Form CMS-10495 Applicable GPO (Attestation) Form and Instruction Modified 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 Modified Repair queued
Form CMS-10495 Open Payments User Guide Form and Instruction Modified Repair queued
Form CMS-10495 AM (Data Collection and Submission) Form and Instruction Modified 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 Modified Repair queued
Form CMS-10495 Review and Dispute Screen Shots Form and Instruction Modified Repair queued
Form CMS-10495 Dispute Resolution and Correction (Physicians) Form and Instruction Modified Repair queued
Form CMS-10495 Assumptions Form and Instruction Modified Repair queued
Form CMS-10495 AM (Assumptions Document) Form and Instruction Modified Repair queued
Form CMS-10495 Attestation Form and Instruction Modified Repair queued
Form CMS-10495 AM (Attestation) Form and Instruction Modified Repair queued
Form CMS-10495 Registration Form and Instruction Modified Repair queued
Form CMS-10495 Teaching Hospitals (Registration) Form and Instruction Modified Repair queued
Form CMS-10495 Registration Form and Instruction Modified Repair queued
Form CMS-10495 Physicians (Registration) Form and Instruction Modified Repair queued
Form CMS-10495 Registration Form and Instruction Modified Repair queued
Form CMS-10495 AM (Registration) Form and Instruction Modified Repair queued
CMS-10495 - Supporting Statement A (CMS-1751-F version 20).docx Supporting Statement A Uploaded 2022-05-04 Repair queued
Response to Public Comments - Supporting Statement A 3.2.22.docx Supplementary Document Uploaded 2022-05-04 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
238594 Standardizing Data on Reported Products Removed
238593 Modifying Nature of Payment Categories Removed
238592 Applicable GPO (Data Collection and Submission) Form and Instruction ModifiedGeneral-Research-Ownership Submission Data Elements Screen Shots
238592 Applicable GPO (Data Collection and Submission) Form and Instruction ModifiedOpen Payments User Guide
238592 Applicable GPO (Data Collection and Submission) Form and Instruction Modified
238591 GPO Dispute and Resolution Correction Form and Instruction ModifiedReview and Dispute Email Notifications
238591 GPO Dispute and Resolution Correction Form and Instruction ModifiedReview and Dispute Screen Shots
238591 GPO Dispute and Resolution Correction Form and Instruction Modified
238590 Dispute Resolution and Correction (AM) Form and Instruction ModifiedReview and Dispute Email Notifications
238590 Dispute Resolution and Correction (AM) Form and Instruction ModifiedReview and Dispute Screen Shots
238590 Dispute Resolution and Correction (AM) Form and Instruction Modified
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 ModifiedAttestation
238588 Applicable GPO (Attestation) Form and Instruction Modified
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 ModifiedGeneral-Research-Ownership Submission Data Elements and Screen Shots
230225 AM (Data Collection and Submission) Form and Instruction ModifiedOpen Payments User Guide
230225 AM (Data Collection and Submission) Form and Instruction Modified
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 ModifiedReview and Dispute Email Notifications
212216 Dispute Resolution and Correction (Physicians) Form and Instruction ModifiedReview and Dispute Screen Shots
212216 Dispute Resolution and Correction (Physicians) Form and Instruction Modified
211456 AM (Assumptions Document) Form and Instruction ModifiedAssumptions
211456 AM (Assumptions Document) Form and Instruction Modified
211455 AM (Attestation) Form and Instruction ModifiedAttestation
211455 AM (Attestation) Form and Instruction Modified
211454 AM (Record Retention) Instruction Modified
209365 Teaching Hospitals (Registration) Form and Instruction ModifiedRegistration
209365 Teaching Hospitals (Registration) Form and Instruction Modified
209364 Physicians (Registration) Form and Instruction ModifiedRegistration
209364 Physicians (Registration) Form and Instruction Modified
209363 AM (Registration) Form and Instruction ModifiedRegistration
209363 AM (Registration) Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
11/30/2025 36 Months From Approved 07/31/2024
78,166 0 78,812
1,945,756 0 1,897,790
0 0 0





Reginfo record details
16
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
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
Physicians (Registration) CMS-10495
Standardizing Data on Reported Products
Teaching Hospitals (Registration) CMS-10495

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 78,166 78,812 0 2,554 -3,200 0
Annual Time Burden (Hours) 1,945,756 1,897,790 0 113,205 -65,239 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No