Form CMS-10328 CMS-10328_Physician_Information_Form

Form Approved
OMB No. 0938-1106
(01/2017) pending approval

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

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. Additional Physician Information Forms are available on the CMS
website.

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 compensation 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
5. Noncompliant ownership or investment interest of the physician (See § 411.356)
Yes
No
5.a. Direct or indirect ownership or investment
Indirect
Direct
6. Noncompliant designated health services provided pursuant to referrals made by the physician (See § 411.355)
Yes
No

II. Noncompliant compensation arrangement (§ 411.357), noncompliant ownership or investment interest
(§ 411.356), Noncompliant designated health services provided pursuant to referrals made by the 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 the 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 DHS referred by a physician violated section 1877 of the Act. For example, the disclosing party may have
had a noncompliant equipment lease arrangement with a physician and a noncompliant call coverage arrangement with the same physician
during the lookback period. If there are multiple reasons why DHS referred by 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 involving the
same physician" at the end of this form.

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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, or 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 furnished and supervised (if
applicable) the DHS, where the services were furnished, 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 noncompliant DHS furnished pursuant to
referrals made by the physician.

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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 DHS
provided did not satisfy the requirements of 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

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 terminating 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:

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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 selfreferral 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 the requirements of a service exception. The entries for lines 1 through 6 are based on certain common
requirements of a number of exceptions for compensation arrangements. To complete the entries, determine which 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 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 arrangement for the rental of office space must answer "yes" or "no" to lines 1 through 5 and "N/
A" to line 6."

1. Satisfies the requirement that compensation is 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 or other business generated requirement: State whether the compensation arrangement
satisfied the volume or value of referrals or 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

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N/A

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