OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities

IC 249149 under ICR 202506-0938-006 · OMB 0938-1401.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities
 
Yes Unchanged
 
Required to Obtain or Retain Benefits
 
45 CFR 149.140(d)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf Yes No Fillable Fileable

Health Health Care Services

 

879 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  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 3,801,675 0 0 0 3,801,675 0
Annual IC Time Burden (Hours) 739,158 0 0 0 739,158 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].