Information Collection

Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services

IC 253134 under ICR 202606-0938-017 · OMB 0938-1433.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10791 Right to Receive a Good Faith Estimate of Expected Charges Notice Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services	Form and Instruction
CMS-10791 Right to Receive a Good Faith Estimate of Expected Charg Appendix 1. Right to Receive a Good Faith Estimate of Expected Charges Notice.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.610

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-10791				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 511,748

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: 10 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	511,748	-2,987,194	3,498,942
Annual IC Time Burden (Hours)	755,658	-2,743,284	3,498,942
Annual IC Cost Burden (Dollars)	52,172,709	-304,544,428	356,717,137

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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