Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers

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: 249147

Information Collection (IC) Details

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Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers CCIIO - 10708
 
Yes Unchanged
 
Required to Obtain or Retain Benefits
 
45 CFR 149.420(c)-(i) 45 CFR 149.410(b)-(e)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf Yes No Fillable Fileable

Health Health Care Services

 

17,309 6,502
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   34 %

  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 1,627,046 0 0 0 0 1,627,046
Annual IC Time Burden (Hours) 2,086,326 0 0 0 0 2,086,326
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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