Financial Review

Medicare Self-Referral Disclosure Protocol (CMS-10328)

OMB: 0938-1106

IC ID: 194183

Information Collection (IC) Details

View Information Collection (IC)

Financial Review
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10328 CMS-10328_Physician_Information_Form CMS-10328-Physician-Information.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10328 Self Referral Disclosure CMS-10328-Voluntary-Self-Referral-Disclosure-Protocol.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10328 Group Practice CMS-10328-Group-Practice-Information.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

100 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100 0 0 0 0 100
Annual IC Time Burden (Hours) 1,500 0 0 0 0 1,500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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