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

ICR 202304-0938-008

OMB: 0938-1237

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10495 Applicable GPO (Data Collection and Submission) Form and Instruction	Modified
Form CMS-10495 GPO Dispute and Resolution Correction Form and Instruction	Unchanged
Form CMS-10495 Dispute Resolution and Correction (AM) Form and Instruction	Modified
Form CMS-10495 Applicable GPO (Assumptions Document) Form and Instruction	Unchanged
Form CMS-10495 Applicable GPO (Attestation) Form and Instruction	Unchanged
Form CMS-10495 Applicable GPO (Registration) Form and Instruction	Unchanged
Form CMS-10495 AM (Data Collection and Submission) Form and Instruction	Modified
Form CMS-10495 Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction	Unchanged
Form CMS-10495 Dispute Resolution and Correction (Physicians) Form and Instruction	Unchanged
Form CMS-10495 AM (Assumptions Document) Form and Instruction	Modified
Form CMS-10495 AM (Attestation) Form and Instruction	Unchanged
Form CMS-10495 Teaching Hospitals (Registration) Form and Instruction	Unchanged
Form CMS-10495 Physicians (Registration) Form and Instruction	Unchanged
Form CMS-10495 AM (Registration) Form and Instruction	Modified
CMS-10495 - Supporting Statement A .docx Supporting Statement A	2023-04-13
Response to Public Comments - Supporting Statement A 3.2.22.docx Supplementary Document	2022-05-04

IC Document Collections

IC ID	Document Title	Status
238592	Applicable GPO (Data Collection and Submission) Form and Instruction	Modified
238591	GPO Dispute and Resolution Correction Form and Instruction	Unchanged
238590	Dispute Resolution and Correction (AM) Form and Instruction	Modified
238589	Applicable GPO (Assumptions Document) Form and Instruction	Unchanged
238588	Applicable GPO (Attestation) Form and Instruction	Unchanged
238587	Applicable GPO (Record Retention) Instruction	Unchanged
238586	Applicable GPO (Registration) Form and Instruction	Unchanged
230225	AM (Data Collection and Submission) Form and Instruction	Modified
212217	Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction	Unchanged
212216	Dispute Resolution and Correction (Physicians) Form and Instruction	Unchanged
211456	AM (Assumptions Document) Form and Instruction	Modified
211455	AM (Attestation) Form and Instruction	Unchanged
211454	AM (Record Retention) Instruction	Modified
209365	Teaching Hospitals (Registration) Form and Instruction	Unchanged
209364	Physicians (Registration) Form and Instruction	Unchanged
209363	AM (Registration) Form and Instruction	Modified