Information Collection Request

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

ICR 202303-0938-013 · OMB 0938-1433 · Active

Forms and Documents

Document	Type	Status	Availability
Form CMS-10791 Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services	Form and Instruction	Unchanged	Available
Form CMS-10791 Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services	Form and Instruction	Unchanged	Repair queued
Form CMS-10791 Notice of Right to Good Faith Estimate – Individual Physician Practitioners	Form and Instruction	Unchanged	Available
Form CMS-10791 Notice of Right to Good Faith Estimate – Individual Physician Practitioners	Form and Instruction	Unchanged	Missing upstream
Form CMS-10791 Notice of Right to Good Faith Estimate – Health Care Facilities	Form and Instruction	Modified	Available
Form CMS-10791 Notice of Right to Good Faith Estimate – Health Care Facilities	Form and Instruction	Modified	Repair queued
CMS-10791 - Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-03-29	Available
CMS-10791 - Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-03-29	Missing upstream
CMS-10791 - Non-sub Change Request Memo (Abbreviated GFE) FINAL.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-03-21	Available
CMS-10791 - Non-sub Change Request Memo (Abbreviated GFE) FINAL.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-03-21	Repair queued
CMS-10791_Supporting Statement_112022.docx	Supporting Statement A	Uploaded 2022-11-15	Available
CMS-10791_Supporting Statement_112022.docx	Supporting Statement A	Uploaded 2022-11-15	Missing upstream

IC Document Collections

IC ID	Collection	Type	Status
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	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	202303-0938-001
Agency Tracking No	CCIIO
Date Submitted to OIRA	2023-03-29
Requested Expiration Date	1969-12-31