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Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers

IC 249147 under ICR 202506-0938-006 · OMB 0938-1401.

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

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Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers CCIIO - 10708
 
Yes Unchanged
 
Required to Obtain or Retain Benefits
 
45 CFR 149.410(b)-(e) 45 CFR 149.420(c)-(i)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10780 Yes No Fillable Fileable

Health Health Care Services

 

17,309 6,502
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   34 %

  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 1,627,046 0 0 0 1,627,046 0
Annual IC Time Burden (Hours) 2,086,326 0 0 0 2,086,326 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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