Disclosure of Financial Relationships Report ("DFRR") - Section 5006 of the DRA-CMS 10236

Disclosure of Financial Relationships Report ("DFRR") - Section 5006 of the DRA

Documents and Forms

Document Name Document Type
CMS-10236 Disclosure of Financial Relationship Report (DFRR)-Revised 8-31-07.xls Other-Report
CMS-10236 Attachment 1 - Instructions for Disclosure of Financial Relationship Report (DFRR) Revised83110am.doc Instruction
CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm.doc CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm IC Document

Information Collection (IC) Details

IC Title:	Disclosure of Financial Relationships Report ("DFRR") - Section 5006 of the DRA-CMS 10236	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.361

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Report			CMS-10236 Disclosure of Financial Relationship Report (DFRR)-Revised 8-31-07.xls		Yes	Yes	Paper Only
Instruction			CMS-10236 Attachment 1 - Instructions for Disclosure of Financial Relationship Report (DFRR) Revised83110am.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm	CMS-10236 coverletter to 500 hospitals -- 8-30-07 3pm.doc	10/04/2007

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