Information Collection

Information Collection Requirements in Final Peer Review Organizations Sanction Regulations 42 CFR Sections 1004.40, 1004.50, 1004.60, 1004.70

IC 8053 under ICR 202412-0938-014 · OMB 0938-0444.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-65 Information Collection Requirements in Final Peer Review Organizations Sanction Regulations 42 CFR Sections 1004.40, 1004.50, 1004.50, 1004.60, 1004.70	Form and Instruction
Form CMS-R-65 Sanctions Template Letter Information Collection Requirements in Final Peer Review Organizations Sanction Regulations 42 CFR Sections 1004.40, 1004.50, 1004.50, 1004.60, 1004.70	Form and Instruction
CMS-R-65 Sanctions Template Letter Sanctions Template Letter_09302024_CMS-R-65Final.pdf	Form and Instruction
CMS-R-65 Sanctions Template Letter Sanctions Template Letter_09302024_CMS-R-65Final.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Information Collection Requirements in Final Peer Review Organizations Sanction Regulations 42 CFR Sections 1004.40, 1004.50, 1004.50, 1004.60, 1004.70

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 1004.40 42 CFR 1004.50 42 CFR 1004.70 42 CFR 1004.60

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	CMS-R-65				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	34	16	18
Annual IC Time Burden (Hours)	8,144	3,428	4,716
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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