Information Collection

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

IC 249568 under ICR 202109-0938-015 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
11. HHS - Appendix Good Faith Estimate Data Elements.pdf	Other-Data Elements

IC Title:

Notice of Right to Good Faith Estimate â 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:

table that charts list of 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 %

table that charts list of burden
	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

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.