Information Collection

Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices

IC 253132 under ICR 202303-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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
11. Appendix-HHS Good Faith Estimate Data Elements_04.15.22_clean.pdf	Instruction
11. Appendix-HHS Good Faith Estimate Data Elements_04.15.22_clean.pdf	Instruction

IC Title:

Notice of Right to Good Faith Estimate â Wholly Physician-Owned Private Practices

Agency IC Tracking Number:

CCIIO - 10791

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 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
Instruction					Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120,525

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 5 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	120,525	120,525
Annual IC Time Burden (Hours)	421,837	421,837
Annual IC Cost Burden (Dollars)	50,649,426	50,649,426

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.

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