Information Collection

Legal Review

IC 194182 under ICR 202509-0938-026 · OMB 0938-1106.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10328 Voluntary Self Referral Disclosure Protocol Legal Review	Form and Instruction
Form CMS-10328 Group Practice Information Legal Review	Form and Instruction
Form CMS-10328 Physician Information Legal Review	Form and Instruction
CMS-10328 Voluntary Self Referral Disclosure Protocol CMS_10328_Voluntary_Self_Referral_Disclosure_Protocol_D2.pdf	Form and Instruction
CMS-10328 Group Practice Information CMS_10328_Group_Practice_Information_D3.pdf	Form and Instruction
CMS-10328 Physician Information CMS_10328_Physician_Information_D2.pdf	Form and Instruction

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10328	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10328	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10328	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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	100	0	100
Annual IC Time Burden (Hours)	3,450	-50	3,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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