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

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⚠️ Notice: This information collection may be referencing outdated material.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

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 %

	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

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.