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Information Collection

Notice of Right to Good Faith Estimate – Health Care Facilities

IC 253129 under ICR 202303-0938-013 · OMB 0938-1433.

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Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
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Notice of Right to Good Faith Estimate – Health Care Facilities CCIIO - 10791
 
No Modified
 
Mandatory
 
49 CFR 149.610

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10791 Good Faith Estimates Template and Instructions CMS-10791 - Good Faith Estimate Model Notice Template FINAL 508.pdf Yes Yes Fillable Printable

Health Health Care Services

 

245,336 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 245,336 0 0 0 0 245,336
Annual IC Time Burden (Hours) 1,840,020 0 0 0 0 1,840,020
Annual IC Cost Burden (Dollars) 194,499,927 0 0 0 0 194,499,927

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