OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Complaints Related to Surprise Billing

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

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)

Complaints Related to Surprise Billing
 
Yes Modified
 
Voluntary
 
45 CFR 149.150 45 CFR 149.450

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10779 Consumer Complaint Form - No Surprises Help Desk CMS-10779 - Complaints Professional Form.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10779 Provider Complaint Form - No Surprises Help Desk CMS-10779 - Consumer Complaints Screenshots.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

39,000 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested 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 39,000 0 0 0 39,000 0
Annual IC Time Burden (Hours) 19,500 0 0 0 19,500 0
Annual IC Cost Burden (Dollars) 1,055,730 0 0 0 1,055,730 0

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