Information Collection

Plan and Issuer Disclosure on Patient Protections Against Balance Billing

IC 249146 under ICR 202108-0938-017 · OMB 0938-1401.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1401 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf	Other-Model Notice
CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf	Other-Model Notice

IC Title:

Plan and Issuer Disclosure on Patient Protections Against Balance Billing

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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
Other-Model Notice			CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 879

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 34 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	16,933,056	16,933,056
Annual IC Time Burden (Hours)	187,285	187,285
Annual IC Cost Burden (Dollars)	0	0

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.