PHYSICIAN FINANCIAL INTEREST IN CLINICAL LABORATORIES SURVEY FORM

Forms and Documents

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Collection	Type	Status	Form
114039	PHYSICIAN FINANCIAL INTEREST IN CLINICAL LABORATORIES SURVEY FORM	Form	Migrated

ICR Details

OMB Control No: 0938-0586	ICR Reference No: 199206-0938-011
Status: Historical Active	Previous ICR Reference No: 199106-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: PHYSICIAN FINANCIAL INTEREST IN CLINICAL LABORATORIES SURVEY FORM
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/22/1992
	Date Received in OIRA: 06/24/1992
Terms of Clearance: Approved for use through 9/93 under the following conditions: 1) The HCFA Forms-96 and 97 in the next submission for OMB review are amended to implement published final rules delineating physician financial interest in clinical laboratories for the purposes of Medicare reimbursement; 2) The new Forms include: 1) a narrative describing to respondents the statutory authority for the information collection; 2) definitions of direct and indirect financial interest as set forth in the final rule; and 3) the final rule's criteria for rural exemptions and group practi

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/1993	09/30/1993	07/31/1992
Responses	3,000	0	320,000
Time Burden (Hours)	2,250	0	160,000
Cost Burden (Dollars)	0	0	0

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Abstract: SURVEY OF CLINICAL LABORATORIES (PHYSICIAN OFFICE, INDEPENDENT, HOSPITAL, OR OTHER INSTITUTION-BASED) TO DETERMINE PHYSICIAN OWNERSHIP FINANCIAL INTEREST OR COMPENSATION/RENUMERATION ARRANGEMENTS. THE SURVEY RESPONSES WILL BE USED TO IMPLEMENT PROHIBITIONS TO REFERRAL OF MEDICARE PATIENTS AND PAYMENTS FOR SERVICES TO LABORATORIES WITH SUCH RELATIONSHIPS WITH PHYSICIANS ENACTED IN P.L. 101-239 AS AMENDED BY

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
PHYSICIAN FINANCIAL INTEREST IN CLINICAL LABORATORIES SURVEY FORM	HCFA-96, 97

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,000	320,000	0	0	-317,000	0
Annual Time Burden (Hours)	2,250	160,000	0	0	-157,750	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/24/1992

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