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Federal forms, ICRs, and supporting documents

Information Collection

Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process

IC 262051 under ICR 202309-0938-001 · OMB 0938-1470.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10853
Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process		 Form and Instruction
CMS-10853 Ineligible for Patient-Provider Dispute Resolution or Ad
Appendix 1 SDRE Declining Eligibility or Need More Information Notice.pdf 		Form and Instruction
CMS-10853 Ineligible for Patient-Provider Dispute Resolution or Ad
Appendix 1 SDRE Declining Eligibility or Need More Information Notice.pdf 		Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Form
Appendix 2 PPDR Dispute Initiation Form Notice.pdf 		Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Form (English)
Appendix 2 PPDR Dispute Initiation Form Notice.pdf 		Form and Instruction
cms-10853 SDR Entity Certification Application Data Elements
Appendix 3 SDR Entity Certification Data Elements.pdf 		Form and Instruction
cms-10853 SDR Entity Certification Application Data Elements (Engl
Appendix 3 SDR Entity Certification Data Elements.pdf 		Form and Instruction
CMS-10853 Vendor Management Data Elements
Appendix 4 HHS Vendor Management (VM) Data Elements.pdf 		Form and Instruction
CMS-10853 Vendor Management Data Elements (English)
Appendix 4 HHS Vendor Management (VM) Data Elements.pdf 		Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Process Data Element
Appendix 5 HHS PPDR Data Elements for Patients and Providers.pdf 		Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Process Data Element
Appendix 5 HHS PPDR Data Elements for Patients and Providers.pdf 		Form and Instruction
CMS-10853 Selected Dispute Resolution (SDR) Determination Notice
Appendix 6 PPDR-SDRE Determination Notice.pdf 		Form and Instruction
CMS-10853 Selected Dispute Resolution (SDR) Determination Notice (
Appendix 6 PPDR-SDRE Determination Notice.pdf 		Form and Instruction
CMS-10853 SDRE Selection Notice
Appendix 7 PPDR-SDRE Selection Notice.pdf 		Form and Instruction
CMS-10853 SDRE Selection Notice (English)
Appendix 7 PPDR-SDRE Selection Notice.pdf 		Form and Instruction
CMS-10853 Payment Settlement Form (PPDR)
Appendix 8 PPDR-Payment Settlement Form Notice.pdf 		Form and Instruction
CMS-10853 Payment Settlement Form (PPDR) - English
Appendix 8 PPDR-Payment Settlement Form Notice.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice
Appendix 9 SDRE Confirmation of Receipt of Settlement Notice.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Engli
Appendix 9 SDRE Confirmation of Receipt of Settlement Notice.pdf 		Form and Instruction
CMS-10853 Request for Extension Notice
Appendix 10 Request for Extension Notice.pdf 		Form and Instruction
CMS-10853 Request for Extension Notice (English)
Appendix 10 Request for Extension Notice.pdf 		Form and Instruction
CMS-10853 Request for Extension (Spanish)
Appendix 10 Request for Extension Notice-508_Spanish_Final.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement (Spanish)
Appendix 9 SDRE Confirmation of Receipt of Settlement Notice-508_Spanish_Final.pdf 		Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (Spanish)
Appendix 8 PPDR-Payment Settlement Form Notice-Clean_Spanish_Final.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Selective Notice (Spanish)
Appendix 7 PPDR-SDRE Selection Notice-Clean_Spanish_Final.pdf 		Form and Instruction
cms-10853 PPDR-SDRE Determination Notice (Spanish)
Appendix 6 PPDR-SDRE Determination Notice-508_Spanish_Final.pdf 		Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Spanish)
Appendix 2 PPDR Dispute Initiation Form Notice-Clean_Spanish_Final.pdf 		Form and Instruction
CMS-10853 SDRE Declining Eligibility and Need More Information Not
Appendix 1 SDRE Declining Eligibility or Need More Information Notice-Clean_Spanish_Final.pdf 		Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti
(Arabic) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Dispute Initiation Form
(Arabic) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice
(Arabic) Appendix 6 PPDR-SDRE Determination Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (Arabic)
(Arabic) Appendix 7 PPDR-SDRE Selection Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Payment Settlement Form (Arabic)
(Arabic) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Arabi
(Arabic) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf 		Form and Instruction
CMS-10853 Request for Extension Notice (Arabic)
(Arabic) Appendix 10 Request for Extension Notice_508.pdf 		Form and Instruction
CMS-10853 Request for Extension Notice (Chinese)
(Chiense) Appendix 10 Request for Extension Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Chine
(Chinese) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (Chinese)
(Chinese) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (Chinese)
(Chinese) Appendix 7 PPDR-SDRE Selection Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (Chinese)
(Chinese) Appendix 6 PPDR-SDRE Determination Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Chinese)
(Chinese) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti
(Chinese) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti
(French) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (French)
(French) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (French)
(French) Appendix 6 PPDR-SDRE Determination Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (French)
(French) Appendix 7 PPDR-SDRE Selection Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (French)
(French) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Frenc
(French) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf 		Form and Instruction
CMS-10853 Request for Extension Notice (French)
(French) Appendix 10 Request for Extension Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti
(Korean) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Korean)
(Korean) Appendix 2 PPDR Dispute Initiation Form Notice-508.pdf 		Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Korean)
(Korean) Appendix 7 PPDR-SDRE Selection Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti
(Tagalog) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf 		Form and Instruction
cms-10853 PPDR Dispute Initiation Form Notice (Tagalog)
(Tagalog) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (Tagalog)
(Tagalog) Appendix 6 PPDR-SDRE Determination Notice_508.pdf 		Form and Instruction
cms-10853 PPDR-SDRE Selection Notice (Tagalog)
(Tagalog) Appendix 7 PPDR-SDRE Selection Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-Payment Settlement Form Notice (Tagalog)
(Tagalog) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Tagal
(Tagalog) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf 		Form and Instruction
CMS-10853 Request for Extension Notice (Tagalog)
(Tagalog) Appendix 10 Request for Extension Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti
(Vietnamese) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Vietnamese)
(Vietnamese) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (Vietnamese)
(Vietnamese) Appendix 6 PPDR-SDRE Determination Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (Vietnamese)
(Vietnamese) Appendix 7 PPDR-SDRE Selection Notice_508.pdf 		Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (Vietnamese)
(Vietnamese) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf 		Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Vietn
(Vietnamese) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf 		Form and Instruction
CMS-108i53 Request for Extension Notice (Vietnamese)
(Vietnamese) Appendix 10 Request for Extension Notice_508.pdf 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Form and Instruction CMS-10853 Ineligible for Patient-Provider Dispute Resolution or Additional Information Needed (English) Appendix 1 SDRE Declining Eligibility or Need More Information Notice.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Patient-Provider Dispute Resolution Form (English) Appendix 2 PPDR Dispute Initiation Form Notice.pdf Yes Yes Fillable Fileable
Form and Instruction cms-10853 SDR Entity Certification Application Data Elements (English) Appendix 3 SDR Entity Certification Data Elements.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Vendor Management Data Elements (English) Appendix 4 HHS Vendor Management (VM) Data Elements.pdf Yes No Fillable Printable
Form and Instruction CMS-10853 Patient-Provider Dispute Resolution Process Data Elements (English) Appendix 5 HHS PPDR Data Elements for Patients and Providers.pdf Yes No Fillable Printable
Form and Instruction CMS-10853 Selected Dispute Resolution (SDR) Determination Notice (English) Appendix 6 PPDR-SDRE Determination Notice.pdf Yes No Fillable Printable
Form and Instruction CMS-10853 SDRE Selection Notice (English) Appendix 7 PPDR-SDRE Selection Notice.pdf Yes No Fillable Printable
Form and Instruction CMS-10853 Payment Settlement Form (PPDR) - English Appendix 8 PPDR-Payment Settlement Form Notice.pdf Yes No Fillable Printable
Form and Instruction CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (English) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice.pdf Yes No Fillable Printable
Form and Instruction CMS-10853 Request for Extension Notice (English) Appendix 10 Request for Extension Notice.pdf Yes No Fillable Printable
Form and Instruction CMS-10853 Request for Extension (Spanish) Appendix 10 Request for Extension Notice-508_Spanish_Final.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Confirmation of Receipt of Settlement (Spanish) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice-508_Spanish_Final.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR Payment Settlement Form Notice (Spanish) Appendix 8 PPDR-Payment Settlement Form Notice-Clean_Spanish_Final.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Selective Notice (Spanish) Appendix 7 PPDR-SDRE Selection Notice-Clean_Spanish_Final.pdf Yes No Fillable Fileable
Form and Instruction cms-10853 PPDR-SDRE Determination Notice (Spanish) Appendix 6 PPDR-SDRE Determination Notice-508_Spanish_Final.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR Dispute Initiation Form Notice (Spanish) Appendix 2 PPDR Dispute Initiation Form Notice-Clean_Spanish_Final.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 SDRE Declining Eligibility and Need More Information Notice (Spanish) Appendix 1 SDRE Declining Eligibility or Need More Information Notice-Clean_Spanish_Final.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 SDRE Declining Eligibility or Need More Information Notice - Arabic (Arabic) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR Dispute Initiation Form (Arabic) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Determination Notice (Arabic) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Selection Notice (Arabic) (Arabic) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR Payment Settlement Form (Arabic) (Arabic) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Arabic) (Arabic) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 Request for Extension Notice (Arabic) (Arabic) Appendix 10 Request for Extension Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 Request for Extension Notice (Chinese) (Chiense) Appendix 10 Request for Extension Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Chinese) (Chinese) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR Payment Settlement Form Notice (Chinese) (Chinese) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Selection Notice (Chinese) (Chinese) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Determination Notice (Chinese) (Chinese) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR Dispute Initiation Form Notice (Chinese) (Chinese) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 SDRE Declining Eligibility or Need More Information Notice (Chinese) (Chinese) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 SDRE Declining Eligibility or Need More Information Notice (French) (French) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR Dispute Initiation Form Notice (French) (French) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Determination Notice (French) (French) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Selection Notice (French) (French) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR Payment Settlement Form Notice (French) (French) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (French) (French) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 Request for Extension Notice (French) (French) Appendix 10 Request for Extension Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Declining Eligibility or Need More Information Notice (Korean) (Korean) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR Dispute Initiation Form Notice (Korean) (Korean) Appendix 2 PPDR Dispute Initiation Form Notice-508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR Dispute Initiation Form Notice (Korean) (Korean) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Declining Eligibility or Need More Information Notice (Tagalog) (Tagalog) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction cms-10853 PPDR Dispute Initiation Form Notice (Tagalog) (Tagalog) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Determination Notice (Tagalog) (Tagalog) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Yes No Fillable Fileable
Form and Instruction cms-10853 PPDR-SDRE Selection Notice (Tagalog) (Tagalog) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR-Payment Settlement Form Notice (Tagalog) (Tagalog) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Tagalog) (Tagalog) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 Request for Extension Notice (Tagalog) (Tagalog) Appendix 10 Request for Extension Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Declining Eligibility or Need More Information Notice (Vietnamese) (Vietnamese) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR Dispute Initiation Form Notice (Vietnamese) (Vietnamese) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Determination Notice (Vietnamese) (Vietnamese) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR-SDRE Selection Notice (Vietnamese) (Vietnamese) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 PPDR Payment Settlement Form Notice (Vietnamese) (Vietnamese) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Vietnamese) (Vietnamese) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Yes No Fillable Fileable
Form and Instruction CMS-108i53 Request for Extension Notice (Vietnamese) (Vietnamese) Appendix 10 Request for Extension Notice_508.pdf Yes No Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 26,659 26,659 0 0 0 0
Annual IC Time Burden (Hours) 322,189 322,189 0 0 0 0
Annual IC Cost Burden (Dollars) 32,112,898 32,112,898 0 0 0 0

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table that charts IC Documents
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.