Information Collection

42 CFR 489.20(w)(1)- (5)- Disclosure of Physician Owners/Investors to Staff Physicians

IC 186813 under ICR 201707-0938-011 · OMB 0938-1034.

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Information Collection (IC) Details

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IC Title:	42 CFR 489.20(w)(1)- (5)- Disclosure of Physician Owners/Investors to Staff Physicians	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489.20(w)(1)-(5)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,479	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,711,616	5,711,351	265
Annual IC Time Burden (Hours)	142,791	142,526	265
Annual IC Cost Burden (Dollars)	0	0	0

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