Patient-Provider Dispute Resolution Process

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx
APPENDIX 10
Standard Notice: Patient and Provider Settle on a Payment Amount After Initiating PatientProvider Dispute Resolution
(For use by health care providers beginning January 1, 2022)
Instructions
Under Section 2799B-7 of the Public Health Service Act, the U.S. Department of Health & Human
Services (HHS) is required to establish a patient-provider dispute resolution process where Selected
Dispute Resolution (SDR) entity can resolve a payment dispute between individuals who are not
enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals
who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals), and
health care provider or health care facility by determining the amount such individual is to pay to such
health care provider or health care facility for the items or services subject to patient-provider dispute
resolution process.
This notice is for use by the health care provider to notify the SDR entity and HHS in the event that all
parties agree to settle on a payment amount after the patient-provider dispute resolution process has been
initiated and prior to the SDR entity making a determination. While the determination by the SDR
entity is pending, the two (2) parties to the patient-provider dispute resolution process (the uninsured (or
self-pay) individual and the health care provider or health care facility) may agree to resolve the dispute
by settling on a payment amount. When the parties settle on the amount, federal standards require the
provider to notify the SDR entity and HHS no later than three (3) business days after the date of the
agreement.
HHS has developed this model notice so that providers or facilities may use it to inform SDR entities
that a settlement has been reached between an uninsured (or self-pay) individual and the health care
provider or facility. To use this model notice, the provider or facility must fill in the blanks with the
appropriate information. HHS considers use of the model notice to be good faith compliance.
Note: The information provided in these instructions is intended only to be a general informal summary
of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal
policy guidance upon which it is based. Readers should refer to the applicable statutes, regulations, and
other interpretive materials for complete and current information.
Providers and facilities should not include these instructions with the documents they give to the
selected SDR entities.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid Office of Management and Budget (OMB) control number. The
valid OMB control number for this information collection is 0938-XXXX. The time required to

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx
complete this information collection is estimated to average XX hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Health Care Provider Notice of Payment Settlement to
Selected Dispute Resolution Entity
A health care provider or facility must complete this form when an
uninsured (or self-pay) individual or the individual’s authorized
representative have resolved a payment dispute outside of the dispute
resolution process.
Federal standards require health care providers and facilities to notify the
Selected Dispute Resolution (SDR) entity, no later than 3 business days
after the date of the settlement.
Please complete the information about the payment agreement.
Today’s date: ___________/_________/__________
SDR Entity Name:
Reference Number:
Provider or Facility Name:

Agreed Payment Amount
Date when the new payment agreement was reached:

___________/_________/__________
Select one:

[ ] We agreed to a new payment amount. The final payment amount for the patient is:
$
[ ] We agreed to provide financial assistance. The final payment amount for the
patient is:
$

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OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Patient Information
Patient Name: First Name

Middle Name

Last Name

(optional) Authorized Representative Name:

Health Care Provider Information
Health Care Provider Name

Hospital or Group Name

Street

City
Email

State

ZIP
Phone

I have included with this form (check one):
[ ] Documentation signed by the patient and agreeing to the new payment amount
[ ] Documentation from the patient agreeing to the new payment in the form of an
email, letter, or fax

[ ] I acknowledge that I am sending this for this form to the SDR entity,
the patient or authorized representative, and the U.S. Department of
Health and Human Services (HHS) by uploading it to
www.cms.gov/nosurprises
Once you submit this form, the SDR entity will confirm receipt of
documentation and notify the health care provider of the reduced SDR
entity fee [owed by/ that will be refunded] by [call/email/
www.cms.gov/nosurprises ].

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