Disclosure Request Form

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

Documents and Forms

Document Name Document Type
Form CMS-10307 Disclosure Request Form Form and Instruction
CMS-10307 Disclosure Request Form CMS-10307 Model Form to Request MH SUD Treatment Limit Information.pdf Form and Instruction
CMS-10307 Disclosure Request Form CMS-10307 Model Form to Request MH SUD Treatment Limit Information.pdf Form and Instruction
CMS-10307 - Model disclosure template - FINAL.docx CMS-10307 - Model Disclosure Template IC Document
CMS-10307 - Model disclosure template - FINAL.docx CMS-10307 - Model Disclosure Template IC Document

Information Collection (IC) Details

IC Title:	Disclosure Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 146.136(d)(2)

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 167,425	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	167,425	-17,308	184,733
Annual IC Time Burden (Hours)	13,952	-1,442	15,394
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.