Information Collection Request

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

ICR 202211-0938-008 · OMB 0938-1433 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1433 can be found here:

Forms and Documents

Document Name	Status
Form CMS-10791 Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction	Unchanged
Form CMS-10791 Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction	Unchanged
Form CMS-10791 Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction	Modified
Justification Non substantive change request.docx Justification for No Material/Nonsubstantive Change	2022-11-15
CMS-10791 - GFE PRA Comment Responses clean.docx Supplementary Document	2022-11-08
15. 60-day Notice Comments Response Summary_04.15.22_clean.pdf Supplementary Document	2022-04-28
CMS-10791_Supporting Statement_112022.docx Supporting Statement A	2022-11-15

IC Document Collections

IC ID	Document Title	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
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
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	202204-0938-013
Agency Tracking No	CCIIO - 10791
Date Submitted to OIRA	2022-11-15
Requested Expiration Date	1969-12-31