OMB control number
Complaints Submission Process under the No Surprises Act (CMS-10779)
OMB 0938-1406 · HHS/CMS.
OMB 0938-1406
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10779 Provider Complaint Form - No Surprises Help Desk | Form and Instruction |
| Form CMS-10779 Consumer Complaint Form - No Surprises Help Desk | Form and Instruction |
 CMS-10779 - Supporting Statement.docx | Supporting Statement A |
 Complaints Related to Surprise Billing |
Form and Instruction |
| Complaints Related to Surprise Billing |
Form and Instruction |
| Complaints Related to Surprise Billing |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202603-0938-002 | Reinstatement without change of a previously approved collection | 2026-03-04 | ||
| 202206-0938-005 | Extension without change of a currently approved collection | 2022-06-07 | Approved with change | |
| 202108-0938-011 | New collection (Request for a new OMB Control Number) | 2021-11-24 | Approved with change |