Referring Providers

Probable Fraud Measurement Pilot

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1192 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10406 Referring Providers Form and Instruction
CMS-10406 Instrument CMS-10406.Instrument.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Referring Providers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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-10406	Instrument	CMS-10406.Instrument.docx		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	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	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	3,250	3,250
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.