Information Collection

Provider Disclosure on Patient Protections Against Balance Billing - States

IC 249127 under ICR 202203-0938-004 · OMB 0938-1401.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1401 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Model Disclosure Notice Regarding Patient Protections Against Surprise Billing Final.pdf	Other-Model Notice
Model Disclosure Notice Regarding Patient Protections Against Surprise Billing Final.pdf	Other-Model Notice

IC Title:

Provider Disclosure on Patient Protections Against Balance Billing - States

Agency IC Tracking Number:

CCIIO - 10780

Is this a Common Form? Yes

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 149.430

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-Model Notice			Model Disclosure Notice Regarding Patient Protections Against Surprise Billing Final.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	11	11
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

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.