Health Care Facilities on Behalf of Health Care Providers and Health Care Facilities

Requirements Related to No Surprise Billing Act, Part II (CMS-10791)

OMB:

IC ID: 249564

Documents and Forms
Document Name
Document Type
Other-Notice
Other-Data Elements
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Health Care Facilities on Behalf of Health Care Providers and Health Care Facilities
 
No New
 
Mandatory
 
45 CFR 149.610

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Notice 1. Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf Yes No Paper Only
Form and Instruction CMS-10791 Good Faith Estimate for Health Care Items and Services 2. Good Faith Estimate Template.pdf Yes Yes Fillable Fileable
Other-Data Elements CMS-10791 - 6. HHS - Appendix Vendor Management (VM) Data Elements.pdf Yes No Printable Only

Health Health Care Services

 

245,336 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   10 %

  Requested 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 245,336 245,336 0 0 0 0
Annual IC Time Burden (Hours) 1,840,020 1,840,020 0 0 0 0
Annual IC Cost Burden (Dollars) 194,499,927 194,499,927 0 0 0 0

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