Medicare Self-Referral Disclosure Protocol (CMS-10328)

ICR 202208-0938-025

OMB: 0938-1106

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Modified
Supplementary Document
2022-09-12
Supporting Statement A
2022-09-12
Supplementary Document
2022-08-30
IC Document Collections
IC ID
Document
Title
Status
194183 Modified
194182 Modified
ICR Details
0938-1106 202208-0938-025
Received in OIRA 201909-0938-006
HHS/CMS CM-FFS
Medicare Self-Referral Disclosure Protocol (CMS-10328)
Revision of a currently approved collection   No
Regular 09/16/2022
  Requested Previously Approved
36 Months From Approved 10/31/2022
200 200
5,000 5,000
0 0

The Affordable Care Act (ACA) was enacted on March 23, 2010. Section 6409 of the ACA requires the Secretary of the Department of Health and Human Services (the "Secretary"), in cooperation with the Office of Inspector General of the Department of Health and Human Services (the "Inspector General"), to establish a Medicare self-referral disclosure protocol ("SRDP") that sets forth a process to enable providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute, section 1877 of the Social Security Act (the Act). In accordance with the ACA, the SRDP was established on September 23, 2010, six months after the date of enactment, and information concerning how to disclose an actual or potential violation of section 1877 of the Act was posted on the CMS website.

US Code: 42 USC 1395nn Name of Law: Limitation on Certain Physician Referrals
   PL: Pub.L. 111 - 148 6409 Name of Law: Medicare self-referral disclosure protocol.
  
None

Not associated with rulemaking

  87 FR 35218 06/09/2022
87 FR 54697 09/07/2022
Yes

2
IC Title Form No. Form Name
Financial Review CMS-10328, CMS-10328, CMS-10328 CMS-10328_Physician_Information_Form ,   Self Referral Disclosure ,   Group Practice
Legal Review CMS-10328, CMS-10328, CMS-10328 Self-Referral_Disclosure_Protocol_Form ,   Physician-Information ,   Group Practice Information

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 200 200 0 0 0 0
Annual Time Burden (Hours) 5,000 5,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
    No
    No
Yes
No
No
No
Stephan McKenzie 410 786-1943 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/16/2022


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