Dispute and Resolution Correction (Teaching Hospitals)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1237 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10495 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction
CMS-10495 Review and Dispute Screen Shots CMS-10495 - Review And Dispute Screen Shots 9.23.2020 - 508 cf.pdf Form and Instruction
CMS-10495 Review and Dispute Email Notifications CMS-10495 - Review_and_Dispute_Email_Notifications 9.23.2020 - 508 cf.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Dispute and Resolution Correction (Teaching Hospitals)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.908(g)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10495	Review and Dispute Screen Shots	CMS-10495 - Review And Dispute Screen Shots 9.23.2020 - 508 cf.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10495	Review and Dispute Email Notifications	CMS-10495 - Review_and_Dispute_Email_Notifications 9.23.2020 - 508 cf.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,202	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,404	1,280	1,124
Annual IC Time Burden (Hours)	38,552	25,851	12,701
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.