Form CMS-10780 Standard Notice and Consent

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)

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

Document [pdf]
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File Typeapplication/pdf
File TitleStandard Notice and Consent Documents Under the No Surprises Act
AuthorCMS/CCIIO
File Modified2021-06-28
File Created2021-06-28

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