Information Collection

Physicians' Referral to Health Care Entities With Which They Have Financial Relationships and Supporting Regulations in 42 CFR, Sections 411.1, 411.350 through 411.357 and 424.22

IC 8654 under ICR 200107-0938-016 · OMB 0938-0846.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Physicians' Referral to Health Care Entities With Which They Have Financial Relationships and Supporting Regulations in 42 CFR, Sections 411.1, 411.350 through 411.357 and 424.22	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10047				No	No

Line of Business:

Subfunction:

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.