Information Collection

Notice of Right to Good Faith Estimate – Individual Physician Practitioners

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1. Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf	Other-Notice
CMS-10791 Good Faith Estimate for Health Care Items and Services 2. Good Faith Estimate Template.pdf	Form and Instruction

IC Title:

Notice of Right to Good Faith Estimate â Individual Physician Practitioners

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-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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 145,887

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

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.