403.906 and 404.908(a) - (g) - Applicable GPO Data Collection and Reporting

Transparency Reports and Reporting of Physician Ownership or Investment Interests (CMS-10419)

Documents and Forms

Document Name Document Type
Form CMS-10419 403.906 and 404.908(a) - (g) - Applicable GPO Data Collection and Reporting Form and Instruction
CMS-10419 Template for Open Payment Data Elements Final rule Open Payments data elements PRA 10 29 14.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	403.906 and 404.908(a) - (g) - Applicable GPO Data Collection and Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.906 42 CFR 403.908 42 CFR 404.908 42 CFR 403.904

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10419	Template for Open Payment Data Elements	Final rule Open Payments data elements PRA 10 29 14.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 420	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	420	0	420
Annual IC Time Burden (Hours)	191,835	-62,965	254,800
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.