Medicare Self-Referral Disclosure Protocol

Forms and Documents

Document Name	Status
Form CMS-10328 Financial Review Form and Instruction	Modified
Form CMS-10328 Legal Review Form and Instruction	Modified
SRDP PRA Crosswalk for Clarifying Edits.pdf Supplementary Document	2011-03-27
CMS-10328 Supporting_Statement_Part_A-3-25-11.docx Supporting Statement A	2011-03-25

IC Document Collections

IC ID	Document Title	Status
194183	Financial Review Form and Instruction	Modified
194182	Legal Review Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1106	ICR Reference No: 201103-0938-015
Status: Historical Active	Previous ICR Reference No: 201008-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Self-Referral Disclosure Protocol
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/06/2011
	Date Received in OIRA: 03/28/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2014	36 Months From Approved	05/31/2011
Responses	100	0	100
Time Burden (Hours)	1,200	0	1,200
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection request identifies the specific information describing the actual or potential violation(s) and the related financial analysis that must be furnished by providers of services and suppliers as part of their voluntary disclosure submissions under section 6409 of the Affordable Care Act.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6409 Name of Law: Medicare self-referral disclosure protocol.
   US Code: 42 USC 1395nn Name of Law: Limitation on Certain Physician Referrals
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 2690	01/14/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 16792	03/25/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Financial Review	CMS-10328	Medicare Self-Referral Disclosure Protocol
Legal Review	CMS-10328	Medicare Self-Referral Disclosure Protocol

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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	100	100	0	0	0	0
Annual Time Burden (Hours)	1,200	1,200	0	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:

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Annual Cost to Federal Government: $338,300

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: 03/28/2011

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