Legal Review

Medicare Self-Referral Disclosure Protocol

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1106 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10328 Legal Review Form and Instruction
CMS-10328 Medicare Self-Referral Disclosure Protocol SRDP_Protocol.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Legal Review	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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-10328	Medicare Self-Referral Disclosure Protocol	SRDP_Protocol.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	50	50
Annual IC Time Burden (Hours)	4,000	3,250	750
Annual IC Cost Burden (Dollars)	0	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.