Information Collection

Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices

IC 253132 under ICR 202606-0938-017 · OMB 0938-1433.

Documents and Forms

Document Name Document Type
Appendix 3. Good Faith Estimate Data Elements.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Right to Good Faith Estimate â Wholly Physician-Owned Private Practices	Agency IC Tracking Number:	CCIIO - 10791

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.610

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Appendix 3. Good Faith Estimate Data Elements.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120,525	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 5 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	120,525	120,525
Annual IC Time Burden (Hours)	421,837	421,837
Annual IC Cost Burden (Dollars)	50,649,426	50,649,426

Documents for IC

Title	Document	Date Uploaded
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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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