Information Collection

Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden

IC 249148 under ICR 202506-0938-006 · OMB 0938-1401.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10780 Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden	Form and Instruction
Form CMS-10780 Standard Notice and Consent Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden	Form and Instruction
CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf	Form and Instruction
CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer â Consumer Burden

Agency IC Tracking Number:

CCIIO - 10780

Is this a Common Form? Yes

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 420(c)-(i) 45 CFR 149.410(b)-(e) (To search for a specific CFR, visit the Code of Federal Regulations.)

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-10780				Yes	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,440,565

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,440,565	2,440,565
Annual IC Time Burden (Hours)	1,830,424	1,830,424
Annual IC Cost Burden (Dollars)	0	0

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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