Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities

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: 249149

Information Collection (IC) Details

View Information Collection (IC)

Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities
 
Yes New
 
Required to Obtain or Retain Benefits
 
45 CFR 149.140(d)

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

 

879 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  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 3,801,675 3,801,675 0 0 0 0
Annual IC Time Burden (Hours) 739,158 739,158 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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