CMS-10791 - Appendix 13 Request for Extension Notice

OMB Control Number: 1210-0169
Expiration Date: 04/30/2022

Appendix 13
Standard Notice: Uninsured (or Self-Pay) Individual, Provider or Facility’s Notification to
Secretary of Health and Human Services Requesting Extension
Instructions
Under Section 2799B-7 of the Public Health Service Act and its implementing regulations, the U.S.
Department of Health & Human Services (HHS) is required to establish a patient-provider dispute
resolution process where a Selected Dispute Resolution (SDR) entity can resolve a payment dispute
between individuals who are not enrolled in a group health plan, or group or individual health
insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB)
program health benefits plan (uninsured individuals), or who are not seeking to file a claim with their
group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals), and
health care provider, facility, or provider of air ambulance services by determining the amount such
individual must pay to their health care provider, facility, or provider of air ambulance services. Under
federal criteria, SDR entities will review initiation notices to determine that an uninsured (or self-pay)
individual is eligible to dispute a bill.
An uninsured (or self-pay) individual can request an extension at any step in the patient-provider
dispute resolution process by submitting a request due to extenuating circumstances to the Secretary of
HHS via the federal IDR portal, or electronic or paper mail. If the uninsured (or self-pay) individual is
able to demonstrate the extension is necessary to address delays due to matters beyond their control or
for good cause, the Secretary has the discretion to provide such an extension.
A provider or facility may request an extension after the patient-provider dispute resolution has started.
Once a dispute has been initiated, the parties may request an extension by submitting a request for
extension due to extenuating circumstances through the Federal IDR portal, or electronic or paper mail
if the extension is necessary to address delays due to matters beyond the control of the parties or for
good cause.
Extensions cannot be granted on payment-related deadlines, including payment of the administrative
fee.
Once the patient-provider dispute resolution process has started, the Secretary will consider granting
extensions in the following circumstance:
(i) An extension is necessary to address delays due to matters beyond the control of the parties or
for good cause; and
(ii) The parties attest that prompt action will be taken to ensure that the determination under this
section is made as soon as administratively practicable under the circumstances.

This notice can be used by the uninsured or (self-pay) individual or the provider or facility to request
an extension from HHS. To use this standard notice, the uninsured or (self-pay) individual or the
provider or facility must provide the asked for information in the space allotted.
NOTE: The information provided in these instructions is intended only to be a general informal
summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or
formal policy guidance upon which it is based. Readers should refer to the applicable statutes,
regulations, and other interpretive materials for complete and current information.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
ofinformation unless it displays a valid Office of Management and Budget (OMB) control number.
The valid OMB control number for this information collection is 1210-0169. The time required to
complete this information collection is estimated to average 1.3 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
ReportsClearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Uninsured (or Self-Pay) Individual, Provider or Facility’s Notification to Secretary of
Health and Human Services Requesting Extension

Uninsured (or Self-Pay) Individual [To be filled out by Uninsured (or SelfPay) Individual]
Uninsured (or Self-Pay) Individual
Middle Name
First Name

Last Name

(optional) Authorized Representative Name:
Uninsured (or Self-Pay) Individual’s Contact Information (or Authorized
Representative if Authorized Representative Name is provided above)
Street or P.O. Box

Apartment

City

State

Phone
Contact Preference:

ZIP Code

Email
[ ] By mail

[ ] By email

[ ] By phone

Provider/Facility (if applicable) [To be filled out by provider/facility]
Provider/Facility Name

Provider/Facility Type

Street Address
City

State

ZIP Code

Contact Person

Phone

Email

Contact Preference:

[ ] By mail

[ ] By email

[ ] By phone

Please check the box that best applies to you and fill in the needed information.
I am an uninsured (or self-pay) individual who wants to initiate a dispute. I am requesting
an extension to initiate the process and below is my extenuating circumstance reason.

Extenuating circumstance:

I am an uninsured (or self-pay) individual who has successfully initiated a dispute and I
request an extension to submit documentation (please provide the below information and
attestation).
My Dispute Reference Number
Extenuating circumstance is:

I attest that prompt action will be taken to re-engage the process as soon as
administratively practicable under the circumstances.
I am a provider/facility; I am requesting an extension to submit supporting documentation
(please provide the below information and attestation).
Dispute Reference Number
Extenuating circumstance is:

I attest that prompt action will be taken to re-engage the process as soon as
administratively practicable under the circumstances.

You may submit this request for an extension due to extenuating circumstances by using the
Federal IDR portal, or via electronic or paper mail.
Electronic mail: [email protected]
Paper mail: [SDR Entity’s Address]

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and
any supporting documentation under section 2799B-7 of the Public Health Service Act, as added
by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations
Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to
initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to
determine whether any conflict of interest exists with the independent dispute resolution entity
selected to decide your dispute. The information may also be used to: (1) support a decision on
your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate
selected IDR entity’s compliance with program rules. Providing the requested information is
voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could
cause your dispute to be decided in favor of the provider or facility.