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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details