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

ICR 202211-0938-008

OMB: 0938-1433

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10791 Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction	Unchanged
Form CMS-10791 Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction	Unchanged
Form CMS-10791 Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction	Modified
Justification Non substantive change request.docx Justification for No Material/Nonsubstantive Change	2022-11-15
CMS-10791 - GFE PRA Comment Responses clean.docx Supplementary Document	2022-11-08
15. 60-day Notice Comments Response Summary_04.15.22_clean.pdf Supplementary Document	2022-04-28
CMS-10791_Supporting Statement_112022.docx Supporting Statement A	2022-11-15

IC Document Collections

IC ID	Document Title	Status
253135	Patient-Provider Selected Dispute Resolution Entity Recertification	Unchanged
253134	Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction	Unchanged
253132	Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices Instruction	Unchanged
253130	Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction	Unchanged
253129	Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction	Modified