Information Collection

Notice of Right to Good Faith Estimate – Health Care Facilities

IC 253129 under ICR 202204-0938-013 · OMB 0938-1433.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Notice of Right to Good Faith Estimate â 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:

table that charts list of 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 %

table that charts list of burden
	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

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.