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

IC 249145 under ICR 202203-0938-004 · OMB 0938-1401.

Documents and Forms
Document Name
Document Type
Other-Model Notice
Other-Model Notice
Information Collection (IC) Details

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Title: Provider Disclosure on Patient Protections Against Balance Billing – Facility and Provider Agreements 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 CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf Yes No Paper Only

Health Health Care Services

 

5,822 2,167
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 5,822 0 0 0 0 5,822
Annual IC Time Burden (Hours) 23,288 0 0 0 0 23,288
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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