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OMB Control No: 0938-1106	ICR Reference No: 202509-0938-026
Status: Received in OIRA	Previous ICR Reference No: 202208-0938-025
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Medicare Self-Referral Disclosure Protocol (CMS-10328)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 11/04/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2025
Responses	200	200
Time Burden (Hours)	4,950	5,000
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	200	200	0
Annual Time Burden (Hours)	4,950	5,000	-50
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Cutting Redundancy

Short Statement: For a disclosing party that is disclosing noncompliance arising from the failure of a physician or physicians in a practice that qualifies as a group practice under § 411.352 to satisfy the disclosure requirement for certain imaging services required at § 411.355(b)(7) to submit only one Physician Information Form instead of separate Physician Information Forms for each physician in the practice who made prohibited referrals. This causes a decrease in burden.

Annual Cost to Federal Government: $883,820

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Malcolm Wilson 667 414-0087 malcolm.wilson@cms.hhs.gov