CMS-10419 Physician Ownership Template

Physician Ownership Template

DE #
Data Element Name
Definition / Description
Submission File Information (this section contains data elements which are reported once per submission file)
1

Applicable Manufacturer or
Textual proper name of either the Submitting Applicable Manufacturer or Submitting Applicable
Applicable GPO Submitting File Group Purchasing Organization (GPO) .
Name
If this file contains a single Applicable Manufacturer/GPO's set of payment(s) and/or transfer(s) of
value records, this Applicable Manufacturer/GPO name will be used for all records in the file.

Data Type

Format

Required?

Field Size

Validation

Publicly
Displayed

Text

Free form text

Yes

≤ 100 Char

Match the name
on file for
associated
Registration ID

Yes

System generated

System generated

Yes

System
generated

Match the
Registration ID
on file

No

If this file contains a Consolidated Report, this Applicable Manufacturer/GPO Name will be used as the
Consolidated Reporter and the Applicable Manufacturer/GPO Names and OPEN PAYMENTS system
IDs of the sub-companies making the payments/transfers of value will be recorded with every
payment or transfer of value record in the file.
2

Applicable Manufacturer or
Applicable GPO
Submitting File Registration ID

OPEN PAYMENTS system generated identifier used to identify the Applicable Manufacturer or GPO
(populated only with CMS provided identifier).
If this file contains a single Applicable Manufacturer/GPO's set of payment/transfer of value records,
this Applicable Manufacturer/GPO ID will be used for all records in the file.
If this file contains a Consolidated Report, this Applicable Manufacturer/GPO ID will be used as the
Consolidated Reporter and the Applicable Manufacturer/GPO Names and OPEN PAYMENTS System
IDs of the sub-companies making the payments/transfers of value will be recorded with every
payment/transfer of value record in the file.

3

Consolidated Report Indicator

Indicator showing if this submission file constitutes a Consolidated Report.

Boolean

"Y" = Yes;
"N" = No

Yes

1 Char

Limited to
characters Y or
N.

No

4

Resubmission File Indicator

Indicator showing if this submission file contains payment(s) and/or transfer(s) of value that are
amended or corrected versions of previously submitted records.

Boolean

"Y" = Yes;
"N" = No

Yes

1 Char

No

5

Original File Submission ID

OPEN PAYMENTS system generated identifier used to identify the original file submission. This data

system generated

system generated

Yes IF

system
generated

Limited to
characters Y or
N.
Matches
Original File
Submission ID
on file for
associated
Registration ID

Validation by
CMS

Yes

will be reported to the submitter after a successful submission and should only be reported back in a
resubmission for file identification purposes.

Line 4
Resubmission File
Indicator = "Y"

No

Submission Record Information (all sections from here to end of template contain data elements that are reported once per physician ownership/investment record)
Physician Demographic Information
6

Ownership/Investment
Physician's First Name

Textual first name, as listed in the National Plan & Provider Enumeration System (NPPES) of the
physician with the ownership or investment interest being reported.

Text

Free form text

Yes

≤ 20 Char

7

Ownership/Investment
Physician's Middle Name

Textual middle initial or middle name, as listed in the National Plan & Provider Enumeration System
(NPPES) of the physician with the ownership or investment interest being reported.

Text

Free form text

No

≤ 20 Char

8

Ownership/Investment
Physician's Last Name

Textual last name, as listed in the National Plan & Provider Enumeration System (NPPES) of the
physician with the ownership or investment interest being reported.

Text

Free form text

Yes

≤ 35 Char

9

Ownership/Investment
Physician's Name Suffix

Name suffix, as listed in the National Plan & Provider Enumeration System (NPPES) of the physician
with the ownership or investment interest being reported.

Text

Free form text

No

≤ 5 Char

Yes

10

Ownership/Investment
Physician's Business Street
Address Line 1

The first line of the primary practice street address of the physician with the ownership or investment Text
interest being reported.

Two line address format;
First line contains building number,
street name, street identifier

Yes

≤ 55 Char

Yes

11

Ownership/Investment
Physician's Business Street
Address Line 2

The second line of the primary practice street address of the physician with the ownership or
investment interest being reported.

Two line address format;
Second line contains suite number,
apartment number, post office box
number or other qualifying
information

No

≤ 55 Char

Yes

Text

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

Yes

Validation by
CMS

Yes

1

Physician Ownership Template

DE #
12

Data Element Name

Definition / Description

Data Type

Format

Required?

Field Size

Validation

Publicly
Displayed

Ownership/Investment
Physician's City
Ownership/Investment
Physician's State

The primary practice city of the physician with the ownership or investment interest being reported.

Text

Free form text

Yes

≤ 40 Char

The primary practice state or territory abbreviation of the with the ownership or investment interest
being reported, if the primary practice address is in the United States.

Enumeration

2 character U.S. state or territory
alpha abbreviation

Yes

2 Char

Limited to list of
state
abbreviations
and territories

Yes

14

Ownership/Investment
Physician's Zip Code

The 9 digit zip code for the primary practice location of the physicianwith the ownership or investment Text
interest being reported, if the primary practice address is in the United States.

9 digit numeric zip code

Yes

≤ 9 Char

Either exactly 5
or exactly 9
numeric digits

Yes

15

Ownership/Investment
Physician' s Country

The primary practice/business address country name of the physician with the ownership or
investment interest being reported.

Text

Free form text

Yes

≤ 20 Char

Yes

16

Ownership/Investment
Physician' Province

The primary practice/business province name of the physician with the ownership or investment
interest being reported, if the primary practice/business address is outside the United States, and if
applicable.

Text

Free form text

No

≤ 20 Char

Yes

17

Ownership/Investment
Physician's Postal Code

The international postal code for the primary practice/business location of the physician with the
ownership or investment interest being reported, if the primary practice/business address is outside
the United States.

Text

Alphanumeric

Yes IF

≤ 20 Char

Proper length
and format
validated for
each country

Yes

Proper email
format enforced

No

13

Recipient Country
Line 15 is outside the
United States

Yes

18

Ownership/Investment
Physician's Email Address

The primary email address of the physician with the ownership or investment interest being reported. Text

Email Address

No

≤ 100 Char

19

Ownership/Investment
Physician's Primary Type

Primary type of medicine practiced by the physician with the ownership or investment interest being
reported.

"1" = Medical Doctor (MD);
"2" = Doctor of Osteopathy (DO);
"3" = Doctor of Dentistry (DDS);
"4" = Doctor of Podiatric Medicine
(DPM);
"5" = Doctor of Optometry (OD);
"6" = Chiropractor (DCP)

Yes

1 Char

Allowed values
limited to "1",
"2", "3", "4",
"5", or "6"

Yes

20

Ownership/Investment
Individual NPI for Physician (not NPI of any group physician belonging to) or NPI of Teaching Hospital; Text
Physician's or Teaching Hospital required, if applicable.
NPI
The NPI for a teaching hospital will be provided on the teaching hospital list.

Numeric digits only

Yes IF
the Physian has an
NPI

10 Char

Validation by
CMS

No

21

Ownership/Investment
Physician's Specialty
Ownership/Investment
Physician's License State and
License Number

22

Enumeration

Physician's single specialty chosen from the standardized "provider taxonomy" code list.

Text

Text from Standardized Selection

Yes

10 Char

Validation by
CMS
Proper length
and format
validated for
each state

Yes

Paired state and official state license number of the physician with the ownership or investment
interest being reported; the pairing includes the 2 letter state abbreviation, followed by a hyphen,
followed by the state license number and may include up to 5 "Physician License State and License
Number" pairs, if a physician is licensed in multiple states.

Alphanumeric

Maximum of 5 comma
separated pairs of the state
and license number; AAXXXXXXXXXXXXXXXXX

Yes

≤ 20 Char per
comma
separated item

Text

Free form text

Yes IF

≤ 100 Char

Matches
AM/GPO names
specified at
registration for
associated
Registration IDs

Yes

System
generated

Matches
Registration
ID(s) on file

No

No

Ownership/Investment Information
23

Applicable Manufacturer or
Applicable GPO Reporting
Ownership Name

Textual proper name of either the Applicable Manufacturer or Applicable GPO reporting the
ownership or investment interest being reported in this record.

Line 3
Consolidated Report
Indicator = "Y"

If this file contains a single Applicable Manufacturer/GPO's report(s) of ownership or investment
interest, this data element will be blank since it was reported in data element #1.

24

Applicable Manufacturer or
Applicable GPO
Reporting Ownership
Registration ID

CMS issued generated alphanumeric identifier for this Applicable Manufacturer or GPO issued during
the registration process.

Alphanumeric string

System generated

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

Yes

2

Physician Ownership Template

DE #
25

Data Element Name

Definition / Description

Resubmitted Ownership Record This data element will be blank for initial file submissions.
ID
For resubmission files - this data element will either be blank (indicating an omitted record is being
submitted in the Resubmission file) or will contain the original ownership record ID (indicating which
record is to be corrected). The original payment/transfer of value record ID is provided by the OPEN

Data Type
Alphanumeric string

Format
System generated

Required?

Field Size

Validation

Yes IF

System
generated

If reported,
matches Initial
Payment Record
ID for given
Original File
Submission ID

Line 4
Resubmission File
Indicator = "Y"
AND
Record is not being
submitted as an
omission from the
original submission

PAYMENTS System.

Publicly
Displayed
No

26

Interest Held by Physician or an Indicator showing if the ownership or investment interest is held by the physician themselves or by an "1" = Physician Covered Recipient;
Immediate Family Member
immediate family member.
"2" = Immediate family member

Yes

1 Char

Yes

27

Dollar Amount Invested

The dollar amount the physician or immediate family member has invested in the Applicable
Manufacturer or Applicable GPO in U.S. Dollars (manufacturer must convert to dollar currency if
necessary).

Monetary amount (USD) in
#####.## format

Yes

12 Char

Yes

28

Value of Interest

The current value (as of the reporting date) of the ownership or investment interest of the physician
or immediate family member.

Monetary amount (USD) in
#####.## format

Yes

12 Char

Yes

29

Terms of Interest

Description of any applicable terms of the ownership or investment interest.

Text

Yes

500 Char

No

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

3