Requirements for Provisions of Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services

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

Documents and Forms

Document Name Document Type
1. Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf Other-Notice

Information Collection (IC) Details

IC Title:	Requirements for Provisions of Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services	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:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,498,942	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 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	3,498,942	3,498,942
Annual IC Time Burden (Hours)	3,538,305	3,538,305
Annual IC Cost Burden (Dollars)	356,717,137	356,717,137

Documents for IC

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.