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

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 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

Information Collection (IC) Details

IC Title:	Medical Malpractice Payer, Peer Review Organization, or Private Accreditation Organization Attestation	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	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 %

	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

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.