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Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices
Requirements Related to Surprise Billing; Part II (CMS-10791)
11. Appendix-HHS Good Faith Estimate Data Elements_04.15.22_clean
Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices
OMB: 0938-1433
OMB.report
HHS/CMS
OMB 0938-1433
ICR 202303-0938-001
IC 253132
Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1433 can be found here:
2023-03-29 - No material or nonsubstantive change to a currently approved collection
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