Medicare Self-Referral Disclosure Protocol (CMS-10328)

OMB 0938-1106

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 2022-10-31 and can be found here.

OMB Details

Financial Review

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10328CMS-10328_Self-Referral_Disclosure_Protocol_FormFillable FileableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.


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