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

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

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.