Information Collection

Patient-Provider Selected Dispute Resolution Entity Certification – First-Time/Initial

IC 249565 under ICR 202109-0938-015 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10791 Patient-Provider Selected Dispute Resolution Entity Certification – First-Time/Initial	Form and Instruction
CMS-10791 - 3. SDRE Declining Eligibility or Need More Information Notice.pdf	Other-Notice
CMS-10791 - 5. HHS - Appendix SDR Entity Certification Data Elements_508c.pdf	Other-Data Elements
CMS-10791 Dispute Initiation Form 4. PPDR - Dispute Initiation Form.pdf	Form and Instruction

IC Title:

Patient-Provider Selected Dispute Resolution Entity Certification â First-Time/Initial

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.620

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10791	Dispute Initiation Form	4. PPDR - Dispute Initiation Form.pdf	Yes	Yes	Fillable Fileable
Other-Notice			CMS-10791 - 3. SDRE Declining Eligibility or Need More Information Notice.pdf	Yes	Yes	Fillable Fileable
Other-Data Elements			CMS-10791 - 5. HHS - Appendix SDR Entity Certification Data Elements_508c.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

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 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	1,872	1,872

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.