Information Collection

Patient-Provider Selected Dispute Resolution Entity Recertification

IC 253135 under ICR 202606-0938-017 · OMB 0938-1433.

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Patient-Provider Selected Dispute Resolution Entity Recertification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.620

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	257	257

Documents for IC

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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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