View RCF
- Agency Submission
RCF ID: 202109-1210-001CFPrevious RCF ID:
Status:
Received in OIRA
Expiration Date: 03/31/2022
Agency/Subagency: DOL/EBSAAgency Tracking No:
Host OMB Control No: 0938-1401Host ICR Reference No: 202108-0938-017
Title: Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in
Description of Agency Usage:
DOL will be using the model notice, Provider Disclosure on Patient Protections Against Balance Billing - Facilities and Providers, for ERISA covered plans.
Authorizing Statute(s):
None
Annual Cost to Federal Government: $0
Agency Contact:
James Butikofer 202 693-8434 [email protected]
Common Form Information Collections (IC) in this RCF:
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Total Request
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
10,367,171
0
10,367,171
0
0
0
Annual Time Burden (Hours)
463,193
0
463,193
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This is a new collection of information.