Information Collection

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

IC 209362 under ICR 201311-0938-022 · OMB 0938-1231.

Documents and Forms

Document Name Document Type
Form CMS-855POH Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest Form and Instruction
CMS-855POH Annual Report of Physician-Owned Hospital Ownership and/ CMS-855(POH).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855POH	Annual Report of Physician-Owned Hospital Ownership and/or Investment Interest	CMS-855(POH).pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 140	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.