Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices

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

Documents and Forms

Document Name Document Type
11. HHS - Appendix Good Faith Estimate Data Elements.pdf Other-Data Elements

Information Collection (IC) Details

IC Title:	Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices	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-Data Elements			11. HHS - Appendix Good Faith Estimate Data Elements.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120,525	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: 5 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	120,525	120,525
Annual IC Time Burden (Hours)	421,838	421,838
Annual IC Cost Burden (Dollars)	50,649,426	50,649,426

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.