Disclosure for Self-Insured Plans Opting-in to State Law

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: 249150

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Disclosure for Self-Insured Plans Opting-in to State Law
 
Yes New
 
Mandatory
 
45 CFR 149.30

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

Health Health Care Services

 

28 0
   
State, Local, and Tribal Governments
 
   34 %

  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 28 28 0 0 0 0
Annual IC Time Burden (Hours) 42 42 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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