Information Collection

Plan and Issuer Disclosure on Patient Protections Against Balance Billing

IC 248136 under ICR 202106-1210-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Model Disclosure Notice Regarding Patient Protections Against Surprise Billing CLEAN 7.9.21.docx	Instruction
Model Disclosure Notice Regarding Patient Protections Against Surprise Billing CLEAN 7.9.21.docx	Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2510 29 CFR 2590

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Model Disclosure Notice Regarding Patient Protections Against Surprise Billing CLEAN 7.9.21.docx		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 440

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 34 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	8,466,479	8,466,479
Annual IC Time Burden (Hours)	93,643	93,643
Annual IC Cost Burden (Dollars)	279,389	279,389

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.