Authorized Agent Designation

National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners: 45 CFR Part 60 Regulations and Forms

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

IC Title:	Authorized Agent Designation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	34	Authorized Agent Designation.pdf	Authorized Agent Designation.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: 183	Number of Respondents for Small Entity: 10

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	183	183
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.