OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Patient-Provider Dispute Resolution Process

IC 249566 under ICR 202109-0938-015 · OMB unassigned.

Documents and Forms
Document Name
Document Type
Other-Data Templates
Other-Model notice
Other-Notice
Other-Notice
Information Collection (IC) Details

View Information Collection (IC)

Patient-Provider Dispute Resolution Process
 
No New
 
Mandatory
 
45 CFR 149.620

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Data Templates 7. HHS - Appendix PPDR Data Elements for Patients and Providers.pdf Yes Yes Paper Only
Other-Model notice 8. PPDR - SDRE Determination Notice.pdf Yes No Paper Only
Other-Notice 9. PPDR - SDRE Selection Notice.pdf Yes No Paper Only
Other-Notice CMS-10791 - 10. PPDR - Payment Settlement Form.pdf Yes No Printable Only

Health Health Care Services

 

26,659 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   34 %

  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 26,659 26,659 0 0 0 0
Annual IC Time Burden (Hours) 255,524 255,524 0 0 0 0
Annual IC Cost Burden (Dollars) 29,764,774 29,764,774 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.