Information Collection List

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Financial Review	Modified	100	1500	0	Form and Instruction	CMS-10328	Group Practice Information
					Form and Instruction	CMS-10328	Physician Information
					Form and Instruction	CMS-10328	Voluntary Self Referral Disclosure
Legal Review	Modified	100	3450	0	Form and Instruction	CMS-10328	Voluntary Self Referral Disclosure Protocol
					Form and Instruction	CMS-10328	Group Practice Information
					Form and Instruction	CMS-10328	Physician Information
Total burden requested under this ICR:		200	4950	0
To view an IC, click on IC Title