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Disclosure for Self-Insured Plans Opting-in to State Law

IC 249150 under ICR 202506-0938-006 · OMB 0938-1401.

Documents and Forms
Document Name
Document Type
Other-Model Notice
Other-Model Notice
Information Collection (IC) Details

View Information Collection (IC)

Disclosure for Self-Insured Plans Opting-in to State Law
 
Yes Unchanged
 
Mandatory
 
45 CFR 149.30

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Notice CMS-10780 - Model Disclosure Notice Regarding Patient Protections Against Surprise Billing.pdf Yes No Paper Only

Health Health Care Services

 

28 0
   
State, Local, and Tribal Governments
 
   34 %

  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 28 0 0 0 28 0
Annual IC Time Burden (Hours) 42 0 0 0 42 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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