Information Collection

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

IC 249564 under ICR 202109-0938-015 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10791 Good Faith Estimate for Health Care Items and Services Health Care Facilities on Behalf of Health Care Providers and Health Care Facilities	Form and Instruction
1. Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf	Other-Notice
CMS-10791 - 6. HHS - Appendix Vendor Management (VM) Data Elements.pdf	Other-Data Elements
CMS-10791 Good Faith Estimate for Health Care Items and Services 2. Good Faith Estimate Template.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.610

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Notice		Yes	No	Paper Only
Form and Instruction	CMS-10791	Yes	Yes	Fillable Fileable
Other-Data Elements		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 245,336

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: 10 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	245,336	245,336
Annual IC Time Burden (Hours)	1,840,020	1,840,020
Annual IC Cost Burden (Dollars)	194,499,927	194,499,927

Documents for IC

table that charts IC Documents
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.

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