OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Requirements Related to Surprise Billing; Part II (CMS-10791)

OMB 0938-1433 · HHS/CMS.

OMB 0938-1433

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10791 Right to Receive a Good Faith Estimate of Expected Charges NoticeForm and Instruction
Form CMS-10791 Right to Receive a Good Faith Estimate of Expected Charges NoticeForm and Instruction
Form CMS-10791 Good Faith Estimates Template and InstructionsForm and Instruction
CMS-10791 - Supporting Statement.docxSupporting Statement A
60-day Comment Response.docxSupplementary Document
60-day Comment Response.docxPublic Comments
Appendix 3. Good Faith Estimate Data Elements_12.10.25(redline).docxSupplementary Document
Appendix 2. Good Faith Estimate Template Notice_12.10.25(redline).docxSupplementary Document
Appendix 1. Right to Receive a Good Faith Estimate of Expected Charges Notice_12.10.25(redline).docxSupplementary Document
CMS-10791 - Crosswalk of Changes.docxSupplementary Document
Patient-Provider Selected Dispute Resolution Entity Recertification Information collection
Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction
Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices Instruction
Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction
Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202606-0938-017 Reinstatement with change of a previously approved collection 2026-07-07
202303-0938-013 No material or nonsubstantive change to a currently approved collection 2023-03-29 Approved without change
202303-0938-001 No material or nonsubstantive change to a currently approved collection 2023-03-21 Approved without change
202211-0938-008 No material or nonsubstantive change to a currently approved collection 2022-11-15 Approved without change
202204-0938-013 New collection (Request for a new OMB Control Number) 2022-04-29 Approved with change