CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing

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)

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1401 can be found here:

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File Type	application/pdf
File Title	Model Disclosure Notice Regarding Patient Protections Against Surprise Billing Instructions for Providers and Facilities
Author	CMS/CCIIO
File Modified	2021-06-28
File Created	2021-06-28