Disclosures Required Regarding Physician Ownership and On-site Availability of an MD/DO (CMS-10225)

OMB 0938-1034

Section 6001(a) of the Patient Protection and Affordable Care Act (the ACA) amended section 1877(d)(2) and (d)(3) of the Act to impose additional restrictions in order to qualify for the rural provider and whole hospital exceptions under the physician self-referral law. Among those restrictions were provisions requiring hospitals to prevent conflicts of interest by disclosing physician ownership or investment interest to patients and also requiring hospitals to take certain steps to ensure patient safety.

The latest form for Disclosures Required Regarding Physician Ownership and On-site Availability of an MD/DO (CMS-10225) expires 2021-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Supporting Statement A for CMS 10225. Clean Copy Version. 02.09.21.docx Supporting Statement A
42 CFR 489.20(w)(4) Receive patient signature on written notice of lack of MD coverage
42 CFR 489.20(w)(2) Distribution of Written Notice of Lack of Physician Coverage in Hospital
42 CFR 411.362(b)(3)(ii)(C) Updating disclosure notice on hospital's public website
42 CFR 489.20(w)(1)- (5)- Disclosure of Physician Owners/Investors to Staff Physicians
42 CFR 411.362(b)(3)(ii)(A) and 489.20(u)(2) - Medical Staff by-Laws and Policies (Attorney)
42 CFR 489.20(u)(1) - Attestation of non-Referring Status (Attorney)
42 CFR 411.362(b)(5)(i) - Disclosures
42 CFR 489.20(u)(1) Privide Physician List to Patients
42 CFR 489.20(u)(1) - Outpatient Disclosure
42 CFR 489.20(u)(1) - Providet Disclosure Form
42 CFR 489.20(u)(1) - Develop Disclosure

All Historical Document Collections

202105-0938-008 Improperly submitted	Reinstatement without change of a previously approved collection	2021-05-21
201707-0938-011 Approved with change	Extension without change of a currently approved collection	2017-07-25
201403-0938-005 Approved without change	Revision of a currently approved collection	2014-03-12
201012-0938-010 Approved without change	Revision of a currently approved collection	2010-12-15
201008-0938-011 Comment filed on proposed rule and continue	Revision of a currently approved collection	2010-08-19
200810-0938-005 Approved without change	Revision of a currently approved collection	2008-10-03
200709-0938-007 Approved without change	New collection (Request for a new OMB Control Number)	2007-09-25

OMB Details

42 CFR 489.20(u)(1) - Create Disclosure

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