Disclosure Request Form

Medical Necessity Disclosure Under MHPAEA and Claims Denial Disclosure Under MHPAEA (CMS-10307)

OMB: 0938-1080

IC ID: 229441

Information Collection (IC) Details

View Information Collection (IC)

Disclosure Request Form
 
No Modified
 
Voluntary
 
45 CFR 146.136(d)(2)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10307 Disclosure Request Form CMS-10307 Model Form to Request MH SUD Treatment Limit Information.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

184,733 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 184,733 0 0 0 0 184,733
Annual IC Time Burden (Hours) 15,394 0 0 0 0 15,394
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10307 - Model Disclosure Template CMS-10307 - Model disclosure template - FINAL.docx 08/30/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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