OMB control number

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

OMB 0938-1034 · HHS/CMS.

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 is listed under ICR 201707-0938-011.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
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	Information collection
42 CFR 489.20(w)(2) Distribution of Written Notice of Lack of Physician Coverage in Hospital	Information collection
42 CFR 411.362(b)(3)(ii)(C) Updating disclosure notice on hospital's public website	Information collection
42 CFR 489.20(w)(1)- (5)- Disclosure of Physician Owners/Investors to Staff Physicians	Information collection
42 CFR 411.362(b)(3)(ii)(A) and 489.20(u)(2) - Medical Staff by-Laws and Policies (Attorney)	Information collection
42 CFR 489.20(u)(1) - Attestation of non-Referring Status (Attorney)	Information collection
42 CFR 411.362(b)(5)(i) - Disclosures	Information collection
42 CFR 489.20(u)(1) Privide Physician List to Patients	Information collection
42 CFR 489.20(u)(1) - Outpatient Disclosure	Information collection
42 CFR 489.20(u)(1) - Providet Disclosure Form	Information collection
42 CFR 489.20(u)(1) - Develop Disclosure	Information collection

All Historical Document Collections

Historical document collections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

OMB Details

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

Federal Enterprise Architecture: Health - Health Care Services