Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden

Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in (CMS-10780)

OMB: 0938-1401

IC ID: 249148

Information Collection (IC) Details

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Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden CCIIO - 10780
 
Yes New
 
Required to Obtain or Retain Benefits
 
45 CFR 420(c)-(i) 45 CFR 149.410(b)-(e)  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf Yes No Fillable Fileable

Health Health Care Services

 

2,440,565 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   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 2,440,565 2,440,565 0 0 0 0
Annual IC Time Burden (Hours) 1,830,424 1,830,424 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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