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Information Collection

Notice of Right to Good Faith Estimate – Individual Physician Practitioners

IC 249569 under ICR 202109-0938-015 · OMB unassigned.

Documents and Forms
Document Name
Document Type
Other-Notice
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Notice of Right to Good Faith Estimate – Individual Physician Practitioners
 
No New
 
Mandatory
 
45 CFR 149.610

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
Form and Instruction CMS-10791 Good Faith Estimate for Health Care Items and Services 2. Good Faith Estimate Template.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

145,887 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   5 %

  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 145,887 145,887 0 0 0 0
Annual IC Time Burden (Hours) 481,426 481,426 0 0 0 0
Annual IC Cost Burden (Dollars) 75,076,368 75,076,368 0 0 0 0

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