Notice of Right to Good Faith Estimate – Individual Physician Practitioners

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

Information Collection (IC) Details

IC Title:	Notice of Right to Good Faith Estimate – 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:

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 %

	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

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.