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.
Document Name |
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Form and Instruction |
Form and Instruction |
Supplementary Document |
Supporting Statement A |
Supplementary Document |
Approved without change |
Revision of a currently approved collection | 2022-09-16 | |
Approved without change |
Extension without change of a currently approved collection | 2019-09-12 | |
Approved with change |
Revision of a currently approved collection | 2016-09-15 | |
Approved without change |
Revision of a currently approved collection | 2014-05-16 | |
Approved without change |
Extension without change of a currently approved collection | 2011-03-28 | |
Approved without change |
New collection (Request for a new OMB Control Number) | 2010-08-10 |
Federal Enterprise Architecture: Health - Health Care Services
Form CMS-10328 | CMS-10328_Self-Referral_Disclosure_Protocol_Form | Fillable Fileable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.