Disclosure Requirement for the In-Office Ancillary Services Exception

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10332 Supporting Statement Part A (CLEAN - 5.9.11).docx	Supporting Statement A	Uploaded 2011-05-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194232	Disclosure Requirement		Modified
194231	Development of Form		Modified

ICR Details

OMB Control No: 0938-1133	ICR Reference No: 201102-0938-005
Status: Historical Active	Previous ICR Reference No: 201008-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Disclosure Requirement for the In-Office Ancillary Services Exception
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/01/2011
	Date Received in OIRA: 02/03/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved
Responses	7,616,760	0	0
Time Burden (Hours)	196,383	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: n order to implement section 6003 of the Affordable Care Act, CMS has proposed to amend 42 C.F.R. 411.355(b). Section 6003 establishes a new disclosure requirement for physicians who refer magnetic resonance imaging, computed tomography, and positron emission tomography (MRI, CT and PET) under the in-office ancillary services exception to the prohibition on physician self-referral (section 1877 of the Social Security Act). Under this new requirement physicians must inform patients in writing, at the time of the referral, that the patient may receive the imaging service from another supplier. The physician must also provide the patient with a list of other suppliers that from whom the patient may obtain the services. The proposed rule provides detail regarding what criteria must be included in the disclosure notifcation and supplier list in order to satisfy this new requirement.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6003 Name of Law: Disclosure requirements for in-office ancillary services exception
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 6003 Name of Law: Disclosure requirements for in-office ancillary services exception

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AP79	Final or interim final rulemaking	75 FR 73170	11/29/2010

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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: 2

table that charts list of burden

IC Title	Form No.	Form Name
Development of Form
Disclosure Requirement

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ICR Summary of Burden

table that charts list 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	7,616,760	0	7,616,760	0	0	0
Annual Time Burden (Hours)	196,383	0	196,383	0	0	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: This is a new information collection request.

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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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 02/03/2011

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