Information Collection

Complaints Related to Surprise Billing

IC 249022 under ICR 202603-0938-002 · OMB 0938-1406.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10779 Consumer Complaint Form - No Surprises Help Desk Complaints Related to Surprise Billing	Form and Instruction
Form CMS-10779 Provider Complaint Form - No Surprises Help Desk Complaints Related to Surprise Billing	Form and Instruction
CMS-10779 Consumer Complaint Form - No Surprises Help Desk CMS-10779 - Complaints Professional Form.pdf	Form and Instruction
CMS-10779 Provider Complaint Form - No Surprises Help Desk CMS-10779 - Consumer Complaints Screenshots.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 149.150 45 CFR 149.450

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-10779				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10779				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 39,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	39,000	39,000
Annual IC Time Burden (Hours)	19,500	19,500
Annual IC Cost Burden (Dollars)	1,055,730	1,055,730

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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