OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities

IC 252194 under ICR 202203-1545-007CF · OMB 1210-0169.

Documents and Forms
Document Name
Document Type
Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-Notice of Certified IDR Entity
Other- Notice of Agreement on an Out
Other-Notice of Offer
Information Collection (IC) Details

View RCF Information Collection (IC)

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
 
New
 
Mandatory
 
29 CFR 2590

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Notice of Open Negotiation 2. Tri-dept - open negotiation period notice clean 9.28.21 (002).docx Yes Yes Fillable Printable
Other-Notice of IDR Initiation 3. Tri-dept - notice of IDR Initiation clean 9.28.21.docx Yes Yes Fillable Printable
Other-Notice of Certified IDR Entity Selection 4. Tri-dept - notice of certified IDR entity selection (data elements) clean 9.28.21.docx Yes Yes Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate 5. Tri-dept - notice of agreement of OON rate (data elements) clean 9.28.21.docx Yes Yes Fillable Printable
Other-Notice of Offer 6. Tri-dept - notice of offer (data elements) clean 9.28.21.docx Yes Yes Fillable Printable

Income Security General Retirement and Disability

 

8,667 0
   
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 13,743 13,743 0 0 0 0
Annual IC Time Burden (Hours) 26,422 26,422 0 0 0 0
Annual IC Cost Burden (Dollars) 60,162 60,162 0 0 0 0

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.