OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Dispute Resolution and Correction (Physicians)

IC 212216 under ICR 202511-0938-012 · OMB 0938-1237.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Dispute Resolution and Correction (Physicians)
 
No Modified
 
Mandatory
 
42 CFR 403.908

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

Health Health Care Services

 

2,183 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,183 0 -29,714 0 0 31,897
Annual IC Time Burden (Hours) 7,837 0 -106,673 0 0 114,510
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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