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Authorized Agent Designation
National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms
OMB: 0915-0126
IC ID: 214936
OMB.report
HHS/HSA
OMB 0915-0126
ICR 202310-0915-003
IC 214936
( )
Documents and Forms
Document Name
Document Type
Form 34
Authorized Agent Designation
Form and Instruction
34 Authorized Agent Designation.pdf
Authorized Agent Designation.pdf
Form and Instruction
Information Collection (IC) Details
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