Notice of Right to Good Faith Estimate – Health Care Facilities

Requirements Related to Surprise Billing; Part II (CMS-10791)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1433 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10791 Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction
CMS-10791 Good Faith Estimates Template and Instructions Good Faith Estimate Template Notice EA.pdf Form and Instruction
CMS-10791 Good Faith Estimates Template and Instructions CMS-10791 - Good Faith Estimate Model Notice Template.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Notice of Right to Good Faith Estimate – Health Care Facilities	Agency IC Tracking Number:	CCIIO - 10791

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 49 CFR 149.610

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10791	Good Faith Estimates Template and Instructions	CMS-10791 - Good Faith Estimate Model Notice Template.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 245,336	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	245,336	245,336
Annual IC Time Burden (Hours)	1,840,020	1,840,020
Annual IC Cost Burden (Dollars)	194,499,927	194,499,927

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.