Information Collection

Disclosure for Self-Insured Plans Opting-in to State Law

IC 249150 under ICR 202203-0938-004 · OMB 0938-1401.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Disclosure for Self-Insured Plans Opting-in to State Law

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.30

Information Collection Instruments:

table that charts list of 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: 28

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 34 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	28	28
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.