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)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10780 Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities Form and Instruction
CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf Form and Instruction
CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 149.140(d)

Information Collection Instruments:

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

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: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,801,675	3,801,675
Annual IC Time Burden (Hours)	739,158	739,158
Annual IC Cost Burden (Dollars)	0	0

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.