OMB control number

Registration, Attestation, Dispute Resolution and Correction, Assumptions Document and Data Retention Requirements for Open Payments (CMS-10495)

OMB 0938-1237 · HHS/CMS.

OMB 0938-1237

Section 6002 of the Affordable Care Act added section 1128G to the Social Security Act (Act), which requires applicable manufacturers and applicable group purchasing organizations (GPOs) of covered drugs, devices, biologicals, or medical supplies to report annually to CMS certain payments or other transfers of value to physicians and teaching hospitals, as well as, certain information regarding the ownership or investment interests held by physicians or the immediate family members of physicians in such entities. Specifically, applicable manufacturers of covered drugs, devices, biologicals, and medical supplies are required to submit on an annual basis the information required in section 1128G(a)(1) of the Act about certain payments or other transfers of value made to physicians and teaching hospitals (collectively called covered recipients) during the course of the preceding calendar year. Similarly, section 1128G(a)(2) of the Act requires applicable manufacturers and applicable GPOs to disclose any ownership or investment interests in such entities held by physicians or their immediate family members, as well as information on any payments or other transfers of value provided to such physician owners or investors. Applicable manufacturers must report the required payment and other transfer of value information annually to CMS in an electronic format. The statute also provides that applicable manufacturers and applicable GPOs must report annually to CMS the required information about physician ownership and investment interests, including information on any payments or other transfers of value provided to physician owners or investors, in an electronic format by the same date. This information collection request includes the Registration, Attestation, Assumptions Document and Data Retention Requirements this program.

The latest form for Registration, Attestation, Dispute Resolution and Correction, Assumptions Document and Data Retention Requirements for Open Payments (CMS-10495) expires 2029-06-30 and is listed under ICR 202511-0938-012.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10495 General-Research-Ownership Submission Data Elements Screen ShotsForm and Instruction
Form CMS-10495 Open Payments User GuideForm and Instruction
Form CMS-10495 Review and Dispute Email NotificationsForm and Instruction
Form CMS-10495 Review and Dispute Screen ShotsForm and Instruction
Form CMS-10495 Review and Dispute Email NotificationsForm and Instruction
Form CMS-10495 Review and Dispute Screen ShotsForm and Instruction
Form CMS-10495 AssumptionsForm and Instruction
Form CMS-10495 AttestationForm and Instruction
Form CMS-10495 RegistrationForm and Instruction
Form CMS-10495 General-Research-Ownership Submission Data Elements and Screen ShotsForm and Instruction
Form CMS-10495 Open Payments User GuideForm and Instruction
Form CMS-10495 Review and Dispute Email NotificationsForm and Instruction
Form CMS-10495 Review and Dispute Screen ShotsForm and Instruction
Form CMS-10495 Review and Dispute Email NotificationsForm and Instruction
Form CMS-10495 Review and Dispute Screen ShotsForm and Instruction
Form CMS-10495 AssumptionsForm and Instruction
Form CMS-10495 AttestationForm and Instruction
Form CMS-10495 RegistrationForm and Instruction
Form CMS-10495 RegistrationForm and Instruction
Form CMS-10495 RegistrationForm and Instruction
CMS-10495 Supporting Statement.docxSupporting Statement A
Applicable GPO (Data Collection and Submission) Form and Instruction
Applicable GPO (Data Collection and Submission) Form and Instruction
GPO Dispute and Resolution Correction Form and Instruction
GPO Dispute and Resolution Correction Form and Instruction
Dispute Resolution and Correction (AM) Form and Instruction
Dispute Resolution and Correction (AM) Form and Instruction
Applicable GPO (Assumptions Document) Form and Instruction
Applicable GPO (Attestation) Form and Instruction
Applicable GPO (Record Retention) Instruction
Applicable GPO (Registration) Form and Instruction
AM (Data Collection and Submission) Form and Instruction
AM (Data Collection and Submission) Form and Instruction
Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction
Dispute and Resolution Correction (Teaching Hospitals) Form and Instruction
Dispute Resolution and Correction (Physicians) Form and Instruction
Dispute Resolution and Correction (Physicians) Form and Instruction
AM (Assumptions Document) Form and Instruction
AM (Attestation) Form and Instruction
AM (Record Retention) Instruction
Teaching Hospitals (Registration) Form and Instruction
Physicians (Registration) Form and Instruction
AM (Registration) Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202511-0938-012 Extension without change of a currently approved collection 2025-12-08
202407-0938-016 No material or nonsubstantive change to a currently approved collection 2024-07-25 Approved without change
202304-0938-008 Revision of a currently approved collection 2023-04-13 Approved without change
202112-0938-008 Revision of a currently approved collection 2022-05-05 Approved without change
202107-0938-014 Revision of a currently approved collection 2021-08-02 Comment filed on proposed rule and continue
202102-0938-019 Extension without change of a currently approved collection 2021-03-01 Approved without change
201911-0938-008 Revision of a currently approved collection 2019-11-21 Approved with change
201907-0938-008 Revision of a currently approved collection 2019-08-26 Comment filed on proposed rule and continue
201707-0938-018 Revision of a currently approved collection 2017-08-01 Approved with change
201407-0938-004 Revision of a currently approved collection 2014-07-02 Approved without change
201311-0938-023 New collection (Request for a new OMB Control Number) 2013-11-18 Approved with change

OMB Details

AM (Registration)

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
FormNameElectronic accessType
Form CMS-10495RegistrationFillable FileableForm and instruction

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