Title: Provider Disclosure on Patient Protections Against Balance Billing – Facility and Provider Agreements

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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf Other-Model Notice
CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf Other-Model Notice

Information Collection (IC) Details

IC Title:	Title: Provider Disclosure on Patient Protections Against Balance Billing – Facility and Provider Agreements	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,822	Number of Respondents for Small Entity: 2,167

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,822	5,822
Annual IC Time Burden (Hours)	23,288	23,288
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.