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Federal forms, ICRs, and supporting documents

Information Collection

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

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Notice
Other-Data Elements
Form and Instruction
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Patient-Provider Selected Dispute Resolution Entity Certification – First-Time/Initial
 
No New
 
Mandatory
 
45 CFR 149.620

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

3 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  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 3 3 0 0 0 0
Annual IC Time Burden (Hours) 16 16 0 0 0 0
Annual IC Cost Burden (Dollars) 1,872 1,872 0 0 0 0

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