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⚠️ Notice: This information collection may be referencing outdated material.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 CMS-10328_Self-Referral_Disclosure_Protocol_Form CMS-10328_Self-Referral_Disclosure_Protocol_Form (1-17-17).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	CMS-10328_Self-Referral_Disclosure_Protocol_Form	CMS-10328_Self-Referral_Disclosure_Protocol_Form (1-17-17).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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	0	100
Annual IC Time Burden (Hours)	3,500	-500	4,000
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.