Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest

Forms and Documents

Document	Type	Status	Availability
Form CMS-855POH Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest	Form and Instruction	New	Available
CMS-855(POH)_Supporting_Statement_Part_A(508).docx	Supporting Statement A	Uploaded 2013-11-15	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
209362	Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest	Form and Instruction	New

ICR Details

OMB Control No: 0938-1231	ICR Reference No: 201311-0938-022
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 20971
Title: Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest
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 without change	Conclusion Date: 04/21/2014
	Date Received in OIRA: 11/18/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved
Responses	140	0	0
Time Burden (Hours)	140	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The primary function of the Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest (CMS 855POH) is to gather information from a physician-owned hospital that reports to Medicare specific ownership, investment and managerial information to determine whether the physician-owned hospital meets specific information that identifies of the owners of the hospital and other information necessary to meet the reporting requirements establish per the Affordable Care Act Ownership Disclosure Provisions.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6001 Name of Law: Affordable Care Act
   PL: Pub.L. 105 - 33 4313 Name of Law: Balanced Budget Act of 1997 (BBA)
   PL: Pub.L. 104 - 134 31001 Name of Law: Debt Collection Improvement Act of 1996
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 6001 Name of Law: Affordable Care Act

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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:
	78 FR 27400	05/10/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 45203	07/26/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest	CMS-855POH	Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest

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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	140	0	140	0	0	0
Annual Time Burden (Hours)	140	0	140	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: $7,000

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: 11/18/2013

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