Medicare Self-Referral Disclosure Protocol

ICR 201103-0938-015

OMB: 0938-1106

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Supplementary Document
2011-03-27
Supporting Statement A
2011-03-25
IC Document Collections
IC ID
Document
Title
Status
194183 Modified
194182 Modified
ICR Details
0938-1106 201103-0938-015
Historical Active 201008-0938-003
HHS/CMS
Medicare Self-Referral Disclosure Protocol
Extension without change of a currently approved collection   No
Regular
Approved without change 05/06/2011
Retrieve Notice of Action (NOA) 03/28/2011
  Inventory as of this Action Requested Previously Approved
05/31/2014 36 Months From Approved 05/31/2011
100 0 100
1,200 0 1,200
0 0 0

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.

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
  
None

Not associated with rulemaking

  75 FR 2690 01/14/2011
76 FR 16792 03/25/2011
No

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

  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
No
No

$338,300
No
No
Yes
No
No
Uncollected
William Parham 4107864669

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
03/28/2011


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