Information Collection

Physician Self-Referral Exceptions for Electronic Prescribing and Electronic Health Records-Donation of Technology

IC 45539 under ICR 201012-0938-005 · OMB 0938-1009.

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Information Collection (IC) Details

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IC Title:	Physician Self-Referral Exceptions for Electronic Prescribing and Electronic Health Records-Donation of Technology	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 411.357(v) 42 CFR 411.357(w)

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,347	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: 50 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	37,388	11,148	26,240
Annual IC Time Burden (Hours)	9,347	2,787	6,560
Annual IC Cost Burden (Dollars)	0	0	0

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