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Information Collection

Notice of Right to Good Faith Estimate – Individual Physician Practitioners

IC 253130 under ICR 202303-0938-013 · OMB 0938-1433.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Notice of Right to Good Faith Estimate – Individual Physician Practitioners CCIIO - 10791
 
No Unchanged
 
Mandatory
 
45 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 Right to Receive a Good Faith Estimate of Expected Charges Notice Right to Receive a Good Faith Estimate of Expected Charges Notice.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

145,887 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   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 145,887 0 0 0 0 145,887
Annual IC Time Burden (Hours) 481,426 0 0 0 0 481,426
Annual IC Cost Burden (Dollars) 75,076,368 0 0 0 0 75,076,368

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