Plan and Issuer Disclosure on Patient Protections Against Balance Billing

Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in

OMB: 0938-1401

IC ID: 249377

Documents and Forms
Information Collection (IC) Details

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Plan and Issuer Disclosure on Patient Protections Against Balance Billing
 
Modified
 
Mandatory
 

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

Health Health Care Services

 

440 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   34 %

  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 8,466,479 0 0 0 0 8,466,479
Annual IC Time Burden (Hours) 84,665 0 0 -8,977 0 93,642
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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