Form CMS-10328 CMS-10328_Self-Referral_Disclosure_Protocol_Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-XXXX

CMS VOLUNTARY SELF-REFERRAL DISCLOSURE PROTOCOL
I. INTRODUCTION
The physician self-referral law: (1) prohibits a physician from making referrals for certain designated health services
(DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial
relationship (ownership, investment, or compensation), unless an exception applies; (2) prohibits the entity from
presenting or causing to be presented claims to Medicare (or billing another individual, entity, or third-party
payer) for those referred services; and (3) establishes a number of specific exceptions and grants the Secretary of
the Department of Health and Human Services (HHS) the authority to create regulatory exceptions for financial
relationships that do not pose a risk of program or patient abuse.
The Affordable Care Act (ACA), enacted on March 23, 2010, provides for the establishment of a voluntary selfreferral disclosure protocol (SRDP), under which providers of services and suppliers may self-disclose actual or
potential violations of the physician self-referral law, section 1877 of the Social Security Act (the “Act”). Section
6409(b) of the ACA grants the Secretary of HHS the authority to reduce the amount due and owing for all
violations of the physician self-referral law. Section 6409(a)(3) of the ACA explicitly states that the SRDP is separate
from the advisory opinion process related to physician referrals set forth in 42 C.F.R. §§ 411.370 through 411.389.
Thus, a provider of services or supplier may not disclose an actual or potential violation through the SRDP and
request an advisory opinion for conduct underlying the same arrangement(s) concurrently.
Section 6402 of the ACA establishes a deadline for reporting and returning overpayments by the later of: (1) the
date which is 60 days after the date on which the overpayment was identified; or (2) the date any corresponding
cost report is due, if applicable. At the time the provider of services or supplier electronically submits a disclosure
under the SRDP (and receives email confirmation from the Centers for Medicare & Medicaid Services (CMS) that the
disclosure has been received), the obligation under section 6402 of the ACA to return the disclosed overpayment
within 60 days will be suspended until a settlement agreement is entered, the provider of services or supplier
withdraws from the SRDP, or CMS removes the provider of services or supplier from the SRDP. See 42 C.F.R. §
401.305(b)(2)(ii).

II. THE SRDP
The SRDP is open to all persons (as defined at § 401.303) who may have received an overpayment as a result of an
actual or potential violation of section 1877 of the Act. For purposes of the SRDP, a person submitting a disclosure
to the SRDP will be referred to as a “disclosing party.” The fact that a disclosing party is already subject to
Government inquiry (including investigations, audits or routine oversight activities) will not automatically preclude
acceptance of a disclosure. The disclosure, however, must be made in good faith. A disclosing party that attempts
to circumvent an ongoing inquiry or fails to fully cooperate during the self-disclosure process will be removed from
the SRDP.
The SRDP cannot be used to obtain a CMS determination as to whether an actual or potential violation of the
physician self- referral law occurred. As stated above and in section 6409(a)(3) of the ACA, the SRDP is separate
from the CMS physician self-referral advisory opinion process. The SRDP is intended to facilitate the resolution of
only matters that, in the disclosing party’s reasonable assessment, are actual or potential violations of the physician
self-referral law. Thus, a disclosing party should make a submission to the SRDP with the intention of resolving its
overpayment liability exposure for the conduct it identified. In keeping with these principles, for each disclosed
noncompliant financial relationship, the disclosing party must either: (a) state that the financial relationship
was noncompliant, or (b) state that, because it cannot confirm that the financial relationship complied with the
physician self-referral law, it is certifying noncompliance with the law.
CMS will review the circumstances surrounding the matter disclosed to determine an appropriate resolution. In
some instances, Medicare contractors may be responsible for processing any identified overpayment. CMS is not
bound by any conclusions made by the disclosing party under the SRDP and is not obligated to resolve the matter
in any particular manner. Nevertheless, CMS will work closely with a disclosing party that structures its disclosure
in accordance with these SRDP instructions to reach an effective and appropriate resolution. As a condition
of disclosing a matter pursuant to the SRDP, the disclosing party agrees that no appeal rights attach to claims
relating to the conduct disclosed if resolved through a settlement agreement. If the disclosing party withdraws
or is removed from the SRDP, the disclosing party may appeal any overpayment demand letter in accordance with
Form CMS-10328 (XX/XX)
Expires XX/XX/XXXX

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applicable regulations. Furthermore, as a condition of entering the SRDP, disclosing parties agree that if they are
denied acceptance into the SRDP, withdraw from the SRDP, or are removed from the SRDP by CMS, the reopening
rules at 42 C.F.R. §§ 405.980 through 405.986 shall apply from the date of the initial disclosure to CMS.

III. COOPERATION WITH THE INSPECTOR GENERAL OF THE DEPARTMENT OF HEALTH AND
HUMAN SERVICES (OIG) AND THE DEPARTMENT OF JUSTICE (DOJ)
Participation in the SRDP is limited to actual or potential violations of the physician self-referral law. OIG’s SelfDisclosure Protocol is available for disclosing conduct that raises potential liabilities under other federal criminal,
civil, or administrative laws. See 63 Fed. Reg. 58399 (Oct. 30, 1998); OIG’s Open Letter to Health Care Providers,
March 24, 2009. For example, conduct that raises liability risks under the physician self-referral law may also raise
liability risks under OIG’s civil monetary penalty authorities regarding the federal anti- kickback statute and should
be disclosed through OIG’s Self-Disclosure Protocol. Disclosing parties should not disclose the same conduct under
both the SRDP and OIG’s Self-Disclosure Protocol.
Upon review of the disclosing party’s submission(s), CMS will coordinate with OIG and DOJ. CMS may conclude
that the disclosed matter warrants a referral to law enforcement for consideration under its civil and/or criminal
authorities. When appropriate, CMS may use a disclosing party’s submission(s) to prepare a recommendation to
OIG and DOJ for resolution of False Claims Act, civil monetary penalty, or other liability. Accordingly, the disclosing
party’s initial decision regarding where to disclose a matter involving noncompliance with section 1877 of the Act
should be made carefully.
Disclosing parties who currently have corporate integrity agreements (CIAs) or certification of compliance
agreements (CCAs) with OIG should also comply with any disclosure or reportable event requirements under such
agreements. Effective September 23, 2010, a reportable event solely related to a physician self-referral issue should
be disclosed to CMS using the instructions set forth in this SRDP with a copy to the disclosing party’s OIG monitor.
Questions about any applicable CIA or CCA requirements should be directed to the disclosing party’s OIG monitor.

IV. INSTRUCTIONS REGARDING THE VOLUNTARY DISCLOSURE PROTOCOL SUBMISSION
The disclosing party will be expected to make a submission as follows.

A. Required elements of a complete disclosure
Effective <>, the disclosing party must submit its disclosure using: (1) the SRDP
Disclosure Form, (2) the Physician Information Form(s), and (3) the Financial Analysis Worksheet (unless the party is
a physician-owned hospital disclosing noncompliance resulting solely from the failure to comply with § 411.362(b)
(3)(C); see section IV.C for more details). The forms, including instructions for completing the forms, are attached to
this document as an appendix. The disclosing party must submit all the information required by all the forms. The
following is a brief summary of the forms and other materials that must be submitted to the SRDP.
1. SRDP Disclosure Form: The SRDP Disclosure Form provides information about the disclosing party, including
information regarding the disclosing party’s history of abuse, pervasiveness of noncompliance, and steps to
prevent future noncompliance.
2. Physician Information Form(s): For each physician included in the disclosure, the disclosing party must submit a
separate Physician Information Form providing details of the noncompliant financial relationship(s) between the
physician and the disclosing party.
3. Financial Analysis Worksheet: The Financial Analysis Worksheet quantifies the overpayment for each physician
included in the disclosure who made referrals in violation of section 1877 of the Act. Effective March 14, 2016,
the financial analysis is limited to the 6-year lookback period at § 401.305(f). The Financial Analysis Worksheet
must be submitted in Microsoft Excel®-compatible format.
4. Certification: The initial disclosure and any related supplemental submission must include a certification signed
by the disclosing party or, in the case of an entity, its Chief Executive Officer, Chief Financial Officer, or other
individual who is authorized by the disclosing party to disclose the matter to CMS and to certify the truthfulness
of the information contained in the disclosure. The signed certification must state that, to the best of the
individual’s knowledge, the information provided contains truthful information and is based on a good faith
effort to bring the matter to CMS’ attention for the purpose of resolving the disclosed potential liabilities
relating to the physician self-referral law.
In addition to all the required information, the disclosing party may submit an optional cover letter, including
information that the party believes may be relevant to CMS’ evaluation of the disclosure.
Form CMS-10328 (XX/XX)

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B. Instructions for submitting the disclosure
The complete disclosure and all relevant supporting documents must be submitted electronically to 1877SRDP@
cms.hhs.gov. In addition, a hard copy of the signed certification only must be sent to: Division of Technical Payment
Policy, ATTN: Provider and Supplier Self-Disclosure, Centers for Medicare & Medicaid Services, 7500 Security
Boulevard, Mailstop C4-25-02, Baltimore, MD 21244-1850. Submissions by facsimile will not be accepted.
When the disclosing party submits a disclosure electronically, CMS will immediately send a response email
acknowledging receipt of the submission. After reviewing the submission, CMS will send a letter to the disclosing
party or its representative either accepting or rejecting the disclosure. In some cases, CMS may request additional
information prior to determining whether to accept or reject the disclosure.

C. Disclosure of noncompliance arising solely from the failure to comply with § 411.362(b)(3)(C)
Parties disclosing noncompliance arising solely from the failure of a physician-owned hospital to disclose physician
ownership on any public website or in any public advertising must continue to use the special instructions, available
at http://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Self_Referral_Disclosure_Protocol.html.

D. Obligation to update
If, after the disclosure is made to CMS, the disclosing party files for bankruptcy, undergoes a change of ownership,
or changes the designated representative, the disclosing party must inform CMS of the changes within 30 days.
Updates must be submitted by e-mail to the following address: [email protected]. Include the word
“UPDATE” in the subject of the e-mail.

V. VERIFICATION
Following the receipt of a disclosing party’s submission, CMS will begin its verification of the disclosed information.
The timeframe for CMS’ verification effort will depend, in large part, upon the quality and thoroughness of the
submissions received. Matters uncovered during the verification process, which are outside of the scope of the
disclosure being verified, may be treated as new matters outside the SRDP.
To facilitate CMS’ verification process, CMS must have access to all financial statements, notes, disclosures, and
other supporting documents without the assertion of privileges or limitations on the information produced. In the
normal course of verification, CMS will not request production of written communications subject to the attorneyclient privilege. However, there may be documents or other materials, which CMS believes are critical to resolving
the disclosure that may be covered by the attorney-client privilege. CMS will discuss with a disclosing party’s counsel
ways to gain access to the underlying information without waiver of protections provided by an appropriately
asserted claim of privilege.
CMS may request additional information, such as financial statements, income tax returns, and other documents,
if needed. If additional information is requested, a disclosing party will be given at least 30 days to furnish the
information.

VI. PAYMENTS
Because of the need to verify the information provided by a disclosing party, CMS will not accept payments of
presumed overpayments determined by the disclosing party prior to the completion of CMS’ review. However, the
disclosing party may place funds in an interest-bearing escrow account to ensure adequate resources have been set
aside to repay amounts owed.
While the matter is under CMS review, the disclosing party must refrain from making repayments relating to
the disclosed matter to the Federal health care programs or their contractors without CMS’ prior consent. If CMS
consents, the disclosing party will be required to acknowledge in writing that the acceptance of the payment does
not constitute the Government’s agreement as to the amount of losses suffered by the programs as a result of the
disclosed matter, and does not relieve the disclosing party of any criminal, civil, or civil monetary penalty liability,
nor does it offer a defense to any further administrative, civil, or criminal actions against the disclosing party. We
remind disclosing parties that section 1877(g)(2) of the Act requires that any amounts collected from individuals
that were billed in violation of the physician self-referral law must be refunded to the individuals on a timely basis.

Form CMS-10328 (XX/XX)

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VII. COOPERATION AND REMOVAL FROM THE SRDP AND TIMELINESS OF DISCLOSURE
The disclosing party’s diligent and good faith cooperation throughout the entire process is essential. Accordingly,
CMS expects to receive documents and information from the disclosing party that relate to the disclosed matter
without the need to resort to compulsory methods. If a disclosing party fails to work in good faith with CMS
to resolve the disclosed matter, the lack of cooperation will be taken into account in CMS’ resolution of the
matter. Likewise, the failure to update CMS regarding changes in ownership, bankruptcy filing, or changes in
the designated representative will be taken into account in assessing the disclosing party’s cooperation. The
intentional submission of false or otherwise untruthful information, as well as the intentional omission of relevant
information, will be referred to DOJ, OIG, or other Federal agencies and could, in itself, result in criminal and/
or civil sanctions, as well as exclusion from participation in the Federal health care programs. Furthermore, it is
imperative for disclosing parties to disclose overpayments in a timely fashion once identified. As stated above,
section 6402 of the ACA establishes a deadline for reporting and returning overpayments by the later of: (1) the
date which is 60 days after the date on which the overpayment was identified; or (2) the date any corresponding
cost report is due, if applicable.

VIII. FACTORS CONSIDERED IN REDUCING THE AMOUNT OWED
The factors CMS may consider in reducing the amount otherwise owed include, but are not limited to: (1)
the nature and extent of the improper or illegal practice; (2) the timeliness of the self-disclosure; and (3) the
cooperation in providing additional information related to the disclosure. Although CMS may consider these
factors in determining whether reduction in any amounts owed is appropriate, CMS is not obligated to reduce
any amounts due and owing. CMS will make an individual determination as to whether a reduction is appropriate
based on the facts and circumstances of each disclosed actual or potential violation. The nature and circumstances
concerning a physician self-referral violation can vary given the scope of the physician self- referral law and the
health care industry. Given this variability, CMS evaluates each matter in order to determine the severity of the
physician self-referral law violation and an appropriate resolution for the conduct.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information
collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850.

Form CMS-10328 (XX/XX)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-XXXX

CMS VOLUNTARY SELF-REFERRAL DISCLOSURE PROTOCOL — CHECKLIST
Checklist of required items for a complete submission:
SRDP Disclosure Form
Physician Information Form(s) (one for each physician included in the disclosure who made referrals in violation

of section 1877 of the Act)

Financial Analysis Worksheet, submitted in Microsoft Excel®-compatible format
Certification

The disclosing party may also submit an optional cover letter. All the items listed above (and the optional cover
letter, if included) must be submitted electronically to [email protected]. In addition, a hard copy of the
certification only must be mailed to Division of Technical Payment Policy, ATTN: Provider and Supplier SelfDisclosure, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Mailstop C4-25-02, Baltimore, MD
21244-1850.
Obligation to update: Disclosing parties are reminded of the obligation to update the disclosure if the disclosing
party files for bankruptcy, undergoes a change of ownership, or changes its designated representative. The update
must be submitted electronically to [email protected] within 30 days of the change. Include the word
“UPDATE” in the subject line of the e-mail.

Form CMS-10328 – Checklist (XX/XX)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-XXXX

SRDP DISCLOSURE FORM — CMS-10328
I. DISCLOSING PARTY
1. Legal Business Name
2. “Doing Business As” name (if applicable)
3. Mailing Address
City

State

4. CMS Certification Number (CCN)

5. National Provider Identifier(s) (NPI)

Zip Code
6. Tax Identification Number (TIN)

7. Is the disclosing party affiliated with a network or system? Note: If multiple entities from a network or system are
submitting self- disclosures, each entity that is separately enrolled in Medicare must submit a separate disclosure.
Yes

No

If yes, provide the name of the network or system:

II. DESIGNATED REPRESENTATIVE
1. Name
2. Address
City

State

3. Telephone

4. E-mail

Zip Code

III. PERVASIVENESS OF NONCOMPLIANCE
For purposes of the SRDP, pervasiveness means how common or frequent the disclosed noncompliance was in
comparison with similar financial relationships between the disclosing party and physicians.
Determine the type(s) of noncompliance being disclosed (i.e., compensation arrangements failing to satisfy an
applicable exception at § 411.357, ownership or investment interest failing to satisfy an applicable exception
at § 411.356, or the provision of services failing to satisfy an applicable exception at § 411.355), and report the
pervasiveness of the noncompliance relative to the disclosing party’s similar financial relationships (in the case of
compensation arrangements or ownership or investment interests) or similar services furnished (in the case of DHS
that failed to meet an applicable exception at § 411.355). When reporting more than one type of noncompliance
(i.e., compensation arrangements that do not satisfy the requirements of an exception at § 411.357; ownership or
investment interests that do not satisfy the requirements of an exception at § 411.356; and/or specific DHS that are
furnished by an entity but do not satisfy the requirements of an exception at § 411.355), the pervasiveness of the
noncompliance may be reported by type of noncompliance or in the aggregate. For disclosures of noncompliant
compensation arrangements, do not include arrangements involving nonmonetary compensation or medical
staff incidental benefits in the determination of the pervasiveness of the noncompliance, unless the disclosed
noncompliance resulted from a failure to comply with § 411.357(k) or § 411.357(m).

Form CMS-10328 – SDRP Disclosure Form (XX/XX)

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The following examples may be helpful.
• The hospital has numerous compensation arrangements with physicians. We estimate that the noncompliant
compensation arrangements disclosed herein represent less than 3 percent of all financial relationships with
physicians.
• Six of the hospital’s 30 call coverage arrangements (20 percent) failed to satisfy the requirements of the
exception for personal service arrangements at § 411.357(d) or fair market value compensation at
§ 411.357(l). The hospital had no other financial relationships with referring physicians.
• The hospital has 25 physician owners. Each physician owner had an ownership or investment interest during
the entire lookback period. One of the physician owners was not authorized to perform services at the
hospital as required at § 411.356(c)(3)(i) for a period of six months during the lookback period.
• In 150 instances during a six-month period, the group practice failed to provide the notice required at
§ 411.355(b)(7). We reviewed the medical records and determined that this represents approximately
10 percent of the services subject to the notice requirement that were furnished by the group practice
during the same six-month period.
• The physician practice provided nonmonetary compensation to 50 referring physicians who were not
part of the physician practice during calendar year 2015. The physician practice exceeded the annual limit
on nonmonetary compensation with respect to two physicians. Neither physician returned the excess
nonmonetary compensation during the period established at § 411.357(k)(3).
Note on the application of the “stand in the shoes” provisions at § 411.354(c): The “stand in the shoes” provisions
determine how arrangements with physician organizations should be counted. If there is a compensation
arrangement with a physician organization, the arrangement is deemed to be an arrangement with all the
physicians that stand in the shoes of the physician organization. For example, assume that a party is disclosing a
noncompliant lease arrangement with a physician organization, and that the organization consists of three owners
(mandatorily standing in the shoes of the organization pursuant to § 411.354(c) (ii)(B)) and two non-owners who
are not permissively standing the shoes of the organization. For purposes of the SRDP, this should be counted as
three arrangements, because the arrangement with the organization is deemed to be an arrangement with the
physicians standing in the shoes of the organization.
Note on violations arising from the failure to qualify as a group practice, as the term is defined at § 411.352. In
certain circumstances, the exceptions for professional services at § 411.355(a) and in-office ancillary services at
§ 411.355(b) are only available to physicians in a group practice. If the disclosed noncompliance arises from the
failure of a physician organization to meet the group practice definition, the financial relationship should be
assessed using § 411.356 (for ownership or investment interests) or § 411.357 (for compensation arrangements).
For example, assume a physician organization has three owners and two non-owner employees; the owners and
employees make referrals to the physician organization for DHS provided in the office; the three owners receive
shares of overall profits divided per capita; and the employees receive productivity bonuses. If the physician
organization does not qualify as a group practice, the in-office ancillary services exception is not available. The
disclosing party must then determine whether an applicable exception at § 411.356 or § 411.357 is satisfied. In this
example, assuming that the financial relationships do not satisfy any applicable exception at § 411.356 or § 411.357,
the owners of the physician organization will have an ownership interest that does not satisfy an exception, and
the owners may also have a noncompliant compensation arrangement. The employees will have a compensation
arrangement that does not satisfy an exception. For purposes of the SRDP, these financial relationships should be
analyzed and reported as noncompliant ownership interests (i.e., failure to satisfy an exception at § 411.356) and/
or noncompliant compensation arrangements (i.e., failure to satisfy an exception at § 411.357). Do not analyze and
report the financial relationships as potential violations of § 411.355.
The following examples illustrate the application of the “stand in the shoes” provisions and the definition of
“group practice” to the report of pervasiveness:
• During each year of the lookback period, the disclosing entity was a party to approximately 100
compensation arrangements with referring physicians or their immediate family members, after considering
the application of the “stand in the shoes” rules. During the lookback period, the disclosing entity was a
party to approximately 300 compensation arrangements, after considering the application of the “stand
in the shoes” rules, as some arrangements lasted more than one year. These included compensation
arrangements for the rental of office space, call coverage arrangements, medical directorships, and other
personal service arrangements. The disclosed noncompliance relates to a total of eight compensation
arrangements (two directly with individual physicians and one with a six-owner physician organization). The
eight arrangements were noncompliant for a total of 90 out of 576 potential months during the lookback
period (8 arrangements x 72 months each in the lookback period).
Form CMS-10328 – SDRP Disclosure Form (XX/XX)

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• During two calendar years, the physician practice compensated its physicians in a manner that did not
comply with § 411.352(g). The physician practice paid productivity bonuses and profit shares that were
determined in a manner that directly related to the volume or value of physicians’ referrals of DHS to the
physician practice. Because the physician practice cannot satisfy the requirements for a group practice, the
in-office ancillary services exception is unavailable to it. The compensation arrangements with the physician
practice’s five employed physicians failed to satisfy the requirements of the exception at § 411.357(c) (or any
other exception). The ownership or investment interests of the physician practice’s three owners do not meet
the requirements of any exception at § 411.356. Therefore, eight of eight financial relationships between
the physician practice and its employed physicians and physician owners were noncompliant for the entirety
of the two calendar years.
Report the pervasiveness of the noncompliance in the space provided below. The disclosing party may also provide additional
details and context to help CMS evaluate the pervasiveness of the noncompliance.

Form CMS-10328 – SDRP Disclosure Form (XX/XX)

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IV. OTHER COMPLIANCE ISSUES AND ACTIVITIES
1. Current government inquiry: Indicate whether the disclosing party knows if the disclosed conduct is under
current inquiry by a Government agency or contractor. If the disclosing party has knowledge of a pending
inquiry, identify the Government agency or contractor, and the individual representatives involved, if known.
The disclosing party must also disclose whether it is under investigation or other inquiry for other matters
relating to a Federal health care program, including any matters it has disclosed to other Government entities,
and provide similar information relating to those other matters.
Current government inquiry:
If yes, explain:

Yes

No

2. History of similar conduct: State whether the disclosing entity has a history of conduct similar to that being
disclosed or any prior criminal, civil or regulatory enforcement action against it.
History of similar conduct:
If yes, explain:

Yes

No

3. Steps taken to prevent future noncompliance: State whether the disclosing party has taken any steps to prevent
future noncompliance. If yes, briefly summarize what steps, if any, the disclosing party has taken. If no, briefly
explain why the disclosing party believes that additional steps are not necessary.
Steps to prevent future noncompliance:

Form CMS-10328 – SDRP Disclosure Form (XX/XX)

Yes

No

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-XXXX

PHYSICIAN INFORMATION FORM — CMS-10328
For each physician included in the disclosure, you must submit a separate Physician Information Form providing
details of the noncompliant financial relationship(s) between the physician and the disclosing party.

I. Physician Information
1. Physician name
2. Physician NPI
3. Physician Organization, if applicable
Physician Organization TIN

Physician Organization NPI

4. Noncompliant compensation arrangement(s) with the physician (See § 411.357)
Yes

No

4.a. Total number of noncompliant compensation arrangements with the physician during the lookback period
4.b. Are any of the disclosed noncompliant arrangements deemed to be arrangements with the physician because the
physician stands in the shoes of a physician organization under § 411.354(c)(1) or § 411.354(c)(2)?
Yes

No

N/A

5. Noncompliant ownership or investment interest with the physician (See § 411.356)
Yes

No

5.a. Direct or indirect ownership or investment
Direct

Indirect

N/A

6. Noncompliant designated health services provided pursuant to referrals made by the physician (See § 411.355)
Yes

No

II. Noncompliant ownership or investment interest (§ 411.356), noncompliant compensation
arrangement (§ 411.357), or prohibited DHS referred by a physician (§ 411.355)
Provide the details required below regarding the noncompliant ownership or investment interest, the
noncompliant compensation arrangement, or the prohibited DHS referred by a physician.
Special instructions for disclosures of multiple noncompliant financial relationships with a single physician: In
certain circumstances, there may be more than one reason why referrals from a physician violated section 1877 of
the Act. For example, the disclosing party may have had a noncompliant equipment lease arrangement with the
physician and a noncompliant call coverage arrangement with the same physician during the lookback period. If
there are multiple reasons why referrals from the physician violated section 1877 of the Act, complete a duplicate
of this section for each reason by clicking the box labeled “Click here to add another reason for noncompliance
with section 1877 of the Act” at the end of this form.

Form CMS-10328 – Physician Information Form (XX/XX)

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A. NARRATIVE EXPLANATION
1. Nature of the compensation arrangement, ownership or investment interest, or noncompliance resulting from
the provision of prohibited services:
• For compensation arrangements:
-- Describe the items, space, equipment, and/or services provided under the arrangement. For example, for
a medical directorship arrangement, describe the typical duties and responsibilities of the director and the
number of hours per week, month, or year that the physician performed such services.
-- Describe the rate of compensation or the amount of remuneration provided under the arrangement (for
example, the monthly rental charge for a lease of office space, the rate of payment for call coverage, the
cash value of nonmonetary compensation). If the rate of compensation changed at some point during the
disclosed period of noncompliance, explain when it changed, the amount it was changed to, and why it
was changed.
-- Provide any additional information that the disclosing party believes is relevant and/or necessary to
understanding the nature of the arrangement.
• For ownership or investment interests:
-- Describe the physician’s ownership interest in the DHS entity making the disclosure. For disclosures
involving physician ownership of hospitals, state whether the physician’s ownership interest is in the
entire hospital, as opposed to a distinct part or department of the hospital. See 42 CFR § 356(c)(3)(iii).
-- Provide any additional information that the disclosing party believes is relevant and/or necessary to
understanding the nature of the ownership interest.
• For noncompliance with an applicable services exception:
-- Describe the circumstances surrounding the provision of the prohibited services. For example, if you are
disclosing a failure to satisfy the requirements of the in-office ancillary services exception at § 411.355(b),
explain who provided the services, where the services were provided, how the services were billed, and
the type of services furnished.
-- Provide any additional information that the disclosing party believes is relevant.
Nature of noncompliant compensation arrangement, noncompliant ownership or investment interest, or prohibited DHS
referred by a physician.

Form CMS-10328 – Physician Information Form (XX/XX)

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2. Nature of noncompliance: Explain the nature of the noncompliance.
• Explanation of the noncompliance:
-- If you are disclosing the failure to comply with an applicable exception at § 411.356 (exceptions for
ownership or investment interests) or § 411.357 (exceptions for compensation arrangements), explain
why the financial relationship failed to comply with the physician self-referral law. For example, if a lease
arrangement was not signed by a physician lessee but otherwise complied with an applicable exception,
the disclosing party could state that “the lease arrangement was not signed by the physician lessee.”
-- If you are disclosing the failure to comply with an applicable exception at § 411.355 (excepted services),
explain why the services provided did not meet the applicable exception.
-- Describe any potential causes of the incident or practice.
-- Provide any additional information that the disclosing party believes is relevant and/or necessary to
understanding the nature of the noncompliance.
NOTE: The disclosing entity must either: (a) certify that the financial relationship was noncompliant (or that
the services failed to satisfy an applicable exception at § 411.355), or (b) state that, because it cannot confirm
that the financial relationship complied with the physician self-referral law, it is certifying noncompliance
with the law.
Nature of noncompliance narrative

Form CMS-10328 – Physician Information Form (XX/XX)

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3. Method of cure or termination: Describe how the financial relationship was brought back into compliance or
otherwise terminated.
• If the financial relationship was ongoing at the time the disclosing party discovered the noncompliance,
explain the steps that the disclosing entity took to either bring the financial relationship back into
compliance or terminate the financial relationship. For example, if a personal service arrangement was out
of compliance because it was not set out in writing, state whether the parties cured the noncompliance by
executing a writing or terminated the arrangement.
NOTE: If the parties brought the arrangement into compliance by executing a signed writing covering the
arrangement, CMS may request copies of the signed writing and other additional information regarding the
arrangement.
• If the arrangement was terminated prior to the discovery of the noncompliance, state when the
arrangement was terminated and the circumstances under which it was terminated. For example, a lease
arrangement may have terminated prior to the discovery of the noncompliance because the physician lessee
vacated the property.
Method of cure or termination:

Form CMS-10328 – Physician Information Form (XX/XX)

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B. RELEVANT DATES
1. Period(s) of noncompliance:
Provide the date range(s) of the noncompliance. The party must provide a date range for the entire period of
noncompliance, even if the noncompliance began prior to the 6-year lookback period.

2. Date of discovery
Provide the date that the party determined that it received an overpayment because it failed to comply with the physician
self-referral law. See § 401.305(a)(2).

C. COMPENSATION ARRANGEMENTS ONLY
For compensation arrangements only, complete lines 1 through 6 below. Do not complete lines 1 through 6 for
noncompliant ownership or investment interests or failure to satisfy a service exception. The entries for lines 1
through 6 are based on certain common requirements of a number of compensation exceptions. To complete
the entries, determine which compensation exception applies to the disclosed compensation arrangement.
For example, for a lease of office space, the exception at § 411.357(a) would be applicable; for a call coverage
arrangement, the exceptions at § 411.357(d) and § 411.357(l) are potentially applicable. After determining the
applicable exception, state whether the requirements in lines 1 through 6 are either satisfied or not satisfied; if the
applicable compensation exception does not require this element, enter N/A. For example, the exception for the
rental of office space imposes the requirements in lines 1 through 5 below, but not the requirement in line 6; thus,
a party disclosing a noncompliant lease arrangement must answer “yes” or “no” to lines 1 through 5 and “N/A” to
line 6.”
1. Compensation set in advance
State whether the amount of compensation was set in advance, if required by an applicable exception. (See, e.g., §
411.357(a)(4)).
Yes
No
N/A
2. Satisfies the volume or value of referrals and other business generated requirement
State whether the compensation arrangement satisfied the volume or value of referrals and other business generated
requirement, if applicable. (See, e.g., § 411.357(a)(5)(i)).
Yes

No

N/A

3. Satisfies the fair market value requirement
State whether the compensation arrangement satisfied the relevant fair market value requirement, if applicable.
(See, e.g., § 411.357(a)(4)).
Yes

No

N/A

4. Satisfies the commercial reasonableness requirement
State whether the compensation arrangement satisfied the commercial reasonableness requirement, if applicable.
(See, e.g., § 411.357(a)(6)).
Yes

No

N/A

5. Satisfies the reasonable and necessary requirement
State whether the compensation arrangement satisfied the reasonable and necessary requirement, if applicable.
(See, e.g., § 411.357(a)(3)).
Yes

No

N/A

6. Satisfies the Federal and State law requirement(s)
State whether, to the best of the disclosing party’s knowledge, the compensation arrangement satisfied the compliance
with Federal and State law requirements, if applicable. (See, e.g., § 411.357(d)(1)(vi)).
Yes

No

N/A

Click here to add another reason for
noncompliance with section 1877 of the Act.

Form CMS-10328 – Physician Information Form (XX/XX)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-XXXX

FINANCIAL ANALYSIS WORKSHEET — CMS-10328
INSTRUCTIONS FOR THE FINANCIAL ANALYSIS WORKSHEET
1. Financial analysis: The disclosing party must provide a financial analysis of the potential overpayment based
on the 6-year lookback period at § 401.305(f). (Unless otherwise requested by CMS, disclosing parties are not
required to report the amount of remuneration between the parties). The financial analysis worksheet must
be submitted in Excel®-compatible format. For each physician included in the disclosure, the worksheet must
include the following:
• Physician’s name
• Physician’s NPI
• Date that the overpayment associated with the physician was identified (see § 401.305(a)(2) for the
definition of “identified”)
• Overpayment arising from the physician’s prohibited referrals, itemized by calendar year (i.e., January
through December)
-- For the yearly itemization of the overpayment, the Worksheet must include 7 columns, each covering an
entire calendar year, even if the 6-year lookback period only falls in a portion of a particular calendar
year, and even if the disclosing party did not receive an overpayment during a particular calendar year.
Example: Assume a party identifies an overpayment on May 14, 2016. The 6-year lookback period for
this overpayment is May 14, 2010 through May 13, 2016. The Worksheet must include columns for
the following calendar years: 2010, 2011, 2012, 2013, 2014, 2015, and 2016. For calendar year 2010 the
disclosing party need only report prohibited referrals from May 14, 2010 through December 31, 2010,
and for calendar year 2016 the disclosing party need only report prohibited referrals from January 1,
2016 through May 13, 2016.
-- For disclosures involving multiple physicians with overpayments identified on different dates, use the
same table for all physicians. If necessary, add columns for additional calendar years to account for the
6-year lookback period for each physician.
Example: Assume a party is disclosing 2 noncompliant arrangements, one identified on December 10,
2016 and the other on January 15, 2017. The Financial Analysis Worksheet must include columns for
calendar years 2010 through 2017.
-- If there are no overpayments in a particular year (for example, if the financial relationship was compliant
during that year, if there were no prohibited referrals for that year, or if there was no financial
relationship between the parties for that year), leave the space blank.
-- There must be a final, total overpayment column for each physician, and the table must also include a
row calculating total overpayment amount for all physicians covered by the disclosure.
2. Methodology: The Excel®-compatible Financial Analysis Worksheet must include a text box describing the
methodology used to set forth the overpayment. The disclosing party must also indicate whether estimates were
used, and, if so, how they were calculated.
Example: The following Financial Analysis Worksheet illustrates the required formatting for the Excel®compatible work sheet. In this example, assume a disclosure was submitted on April 10, 2016 disclosing
noncompliant arrangements with Drs. A, B, and C. In addition, assume the following: (1) for Dr. A, there
was no noncompliant financial relationship between the disclosing party and Dr. A prior to May 1, 2013; the
noncompliance was cured in 2015; and the overpayment was identified on February 18, 2016; (2) for Dr. B,
the noncompliance began in 2009, prior to the opening of 6-year lookback period; the noncompliance was
not cured until 2016; and the overpayment was identified on March 24, 2016; and (3) for Dr. C, there was a
noncompliant financial relationship between Dr. C and the disclosing party prior to 2010, but Dr. C did not make
prohibited referrals to the disclosing party until October 2011; the arrangement terminated in 2015, and the
overpayment was identified on April 5, 2016.

Form CMS-10328 – Financial Analysis Worksheet (XX/XX)

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SAMPLE FINANCIAL ANALYSIS WORKSHEET:

Physician
 Name
Dr.
 A
Dr.
 B
Dr.
 C

NPI
xxxxxxxxxx
xxxxxxxxxx
xxxxxxxxxx

Date
 Over-­‐
payment

Identified
2/18/16
3/24/16
4/5/16

CY
 2010
$

 -­‐
$

 25,000.00
$

 -­‐

CY
 2011
$

 -­‐

$

 10,000.00

$

 5,000.00

CY
 2012
$

 -­‐
$

 75,000.00
$

 25,000.00

CY
 2013
CY
 2014
CY
 2015
CY
 2016
$

 100,000.00

$

 100,000.00

$

 100,000.00 $

 -­‐

$

 50,000.00 $

 50,000.00 $

 50,000.00

$

 10,000.00
$

 20,000.00 $

 20,000.00 $

 20,000.00

$

 -­‐
Total:

TOTAL
$

 300,000.00
$

 270,000.00
$

 90,000.00
$

 660,000.00

Methodology:

 Actual
 data
 was
 used
 to
 determine
 the
 overpayment;
 esKmates
 were
 not
 used.

Form CMS-10328 – Financial Analysis Worksheet (XX/XX)

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