Plan and Issuer Disclosure on Patient Protections Against Balance Billing

No Surprises Act

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Plan and Issuer Disclosure on Patient Protections Against Balance Billing	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:

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 %

	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

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.