OMB control number
Medicare Self-Referral Disclosure Protocol (CMS-10328)
OMB 0938-1106 · HHS/CMS.
OMB 0938-1106
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.
The latest form for Medicare Self-Referral Disclosure Protocol (CMS-10328) expires 2029-07-31 and is listed under ICR 202509-0938-026.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10328 Voluntary Self Referral Disclosure | Form and Instruction |
| Form CMS-10328 Physician Information | Form and Instruction |
| Form CMS-10328 Group Practice Information | Form and Instruction |
| Form CMS-10328 Physician Information | Form and Instruction |
| Form CMS-10328 Group Practice Information | Form and Instruction |
| Form CMS-10328 Voluntary Self Referral Disclosure Protocol | Form and Instruction |
 CMS_10328_Supporting_Statement_Part_A_5_22_2025.docx | Supporting Statement A |
 Financial Review |
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| Financial Review |
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| Financial Review |
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| Legal Review |
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| Legal Review |
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| Legal Review |
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All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202509-0938-026 | Revision of a currently approved collection | 2025-11-04 | ||
| 202208-0938-025 | Revision of a currently approved collection | 2022-09-16 | Approved without change | |
| 201909-0938-006 | Extension without change of a currently approved collection | 2019-09-12 | Approved without change | |
| 201609-0938-006 | Revision of a currently approved collection | 2016-09-15 | Approved with change | |
| 201405-0938-004 | Revision of a currently approved collection | 2014-05-16 | Approved without change | |
| 201103-0938-015 | Extension without change of a currently approved collection | 2011-03-28 | Approved without change | |
| 201008-0938-003 | New collection (Request for a new OMB Control Number) | 2010-08-10 | Approved without change |
OMB Details
Legal Review
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form CMS-10328 | Voluntary Self Referral Disclosure Protocol | Fillable Fileable | Form and instruction |
| Form CMS-10328 | Physician Information | Fillable Fileable | Form and instruction |
| Form CMS-10328 | Group Practice Information | Fillable Fileable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.