Information Collection Request
Requirements Related to Surprise Billing; Part II (CMS-10791)
ICR 202303-0938-001 · OMB 0938-1433 · Historical Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1433 can be found here:
Forms and Documents
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 253135 |  Patient-Provider Selected Dispute Resolution Entity Recertification |
Unchanged | ||
| 253134 | Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services |
Form and Instruction | Unchanged | |
| 253134 | Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services |
Form and Instruction | Unchanged | |
| 253132 | Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices |
Instruction | Unchanged | |
| 253130 | Notice of Right to Good Faith Estimate – Individual Physician Practitioners |
Form and Instruction | Unchanged | |
| 253130 | Notice of Right to Good Faith Estimate – Individual Physician Practitioners |
Form and Instruction | Unchanged | |
| 253129 | Notice of Right to Good Faith Estimate – Health Care Facilities |
Form and Instruction | Modified | |
| 253129 | Notice of Right to Good Faith Estimate – Health Care Facilities |
Form and Instruction | Modified |
ICR Details
| Status | Historical Active |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-1433 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202211-0938-008 |
| Agency Tracking No | CCIIO - 10791 |
| Date Submitted to OIRA | 2023-03-21 |
| Requested Expiration Date | 1969-12-31 |