Information Collection

Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation

IC 245414 under ICR 202310-0915-003 · OMB 0915-0126.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 43 Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	Form and Instruction
43 Medical Malpractice Payer Attestation.pdf Medical Malpractice Payer Attestation.pdf	Form and Instruction
43 Medical Malpractice Payer Attestation.pdf Medical Malpractice Payer Attestation.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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
Form and Instruction	43	Medical Malpractice Payer Attestation.pdf	Medical Malpractice Payer Attestation.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: System of Record Notice 09-15-0054

FR Citation: 88 FR 17854

Number of Respondents: 267

Number of Respondents for Small Entity: 100

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	267	-7	274
Annual IC Time Burden (Hours)	267	-7	274
Annual IC Cost Burden (Dollars)	0	0	0

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.