Provider Disclosure on Patient Protections Against Balance Billing - States

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)

OMB: 0938-1401

IC ID: 249127

Information Collection (IC) Details

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Provider Disclosure on Patient Protections Against Balance Billing - States CCIIO - 10780
 
Yes Unchanged
 
Voluntary
 
45 CFR 149.430

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

Health Health Care Services

 

11 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11 0 0 0 0 11
Annual IC Time Burden (Hours) 33 0 0 0 0 33
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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