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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESForm Approved OMB No. 0938XXXXCMS VOLUNTARY SELFREFERRAL DISCLOSURE PROTOCOL I. INTRODUCTION The physician self referral

How to fill out self-referral disclosure protocol

How to fill out self-referral disclosure protocol

1. Begin by gathering all the necessary information and documentation related to the self-referral.
2. Read through the entire self-referral disclosure protocol carefully to understand the requirements and instruction.
3. Fill out the first section of the form, providing your personal information and contact details.
4. Provide a detailed description of the self-referral, including the reason for the referral and any relevant background information.
5. Clearly state any potential conflicts of interest that may arise from the self-referral.
6. Attach any supporting documents or evidence that can help explain or support your self-referral.
7. Review the completed self-referral disclosure protocol form for accuracy and completeness.
8. Sign and date the form to verify the accuracy of the information provided.
9. Submit the completed form to the appropriate authority or entity responsible for handling self-referrals.
10. Keep a copy of the filled-out self-referral disclosure protocol for your records.

Who needs self-referral disclosure protocol?

1. Anyone who believes they may have a conflict of interest or who needs to disclose an issue related to self-referral should complete the self-referral disclosure protocol.
2. This protocol is commonly used by individuals, professionals, or organizations who want to ensure transparency and compliance in handling self-referrals.

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What is self-referral disclosure protocol?

Self-referral disclosure protocol is a process for healthcare providers to disclose actual or potential violations of the physician self-referral law (Stark Law) to the Centers for Medicare & Medicaid Services (CMS) in order to avoid potential penalties.

Who is required to file self-referral disclosure protocol?

Healthcare providers who have identified actual or potential violations of the Stark Law are required to file a self-referral disclosure protocol.

How to fill out self-referral disclosure protocol?

The self-referral disclosure protocol can be filled out online through the CMS portal by providing detailed information about the disclosed violations and steps taken to prevent future occurrences.

What is the purpose of self-referral disclosure protocol?

The purpose of self-referral disclosure protocol is to encourage healthcare providers to voluntarily disclose and rectify violations of the Stark Law, in exchange for potential reduction in penalties.

What information must be reported on self-referral disclosure protocol?

The self-referral disclosure protocol must include details of the actual or potential violations, the parties involved, the financial impact, corrective actions taken, and any other relevant information.