Information Collection

403.904 and 404.908(a)-(g) - Applicable Manufacturer Data Collection and Reporting

IC 203245 under ICR 201305-0938-006 · OMB 0938-1173.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1173 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10419 403.904 and 404.908(a)-(g) - Applicable Manufacturer Data Collection and Reporting	Form
CMS-10419 Research Template CMS-10419_Research Template.pdf	Form
CMS-10419 Physician Ownership Template CMS-10419_Physician_Ownership_Template.pdf	Form
CMS-10419 General Payments (Non-Research) Template CMS-10419_General_Payments_(Non-Research)_Template (5-15-13).pdf	Form and Instruction

IC Title:

403.904 and 404.908(a)-(g) - Applicable Manufacturer Data Collection and Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.906 42 CFR 403.904 42 CFR 403.908 42 CFR 404.908

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10419	Research Template	CMS-10419_Research Template.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10419	Physician Ownership Template	CMS-10419_Physician_Ownership_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10419	General Payments (Non-Research) Template	CMS-10419_General_Payments_(Non-Research)_Template (5-15-13).pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,150

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: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	1,150	1,150
Annual IC Time Burden (Hours)	4,978,000	4,978,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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