Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services

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⚠️ Notice: This information collection may be referencing outdated material.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 Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction
CMS-10791 Right to Receive a Good Faith Estimate of Expected Charg Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 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	Right to Receive a Good Faith Estimate of Expected Charges Notice	Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,498,942	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: 10 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,498,942	3,498,942
Annual IC Time Burden (Hours)	3,498,942	3,498,942
Annual IC Cost Burden (Dollars)	356,717,137	356,717,137

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.