Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in
CMS-10780 - Standard Notice and Consent
Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities
OMB: 0938-1401
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1401 can be found here: