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

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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Notice of Right to Good Faith Estimate – 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			11. Appendix-HHS Good Faith Estimate Data Elements_04.15.22_clean.pdf		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 %

	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

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.