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Information Collection

Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services

IC 253134 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

View Information Collection (IC)

Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services
 
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

 

3,498,942 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   10 %

  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 3,498,942 0 0 0 0 3,498,942
Annual IC Time Burden (Hours) 3,498,942 0 0 0 0 3,498,942
Annual IC Cost Burden (Dollars) 356,717,137 0 0 0 0 356,717,137

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