OMB control number

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

OMB 0938-1433 · HHS/CMS.

OMB 0938-1433

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10791 Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction
Form CMS-10791 Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction
Form CMS-10791 Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction
Form CMS-10791 Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction
Form CMS-10791 Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction
Form CMS-10791 Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction
CMS-10791 - Change Request.docx Justification for No Material/Nonsubstantive Change
CMS-10791 - Change Request.docx Justification for No Material/Nonsubstantive Change
CMS-10791 - Non-sub Change Request Memo (Abbreviated GFE) FINAL.docx Justification for No Material/Nonsubstantive Change
CMS-10791 - Non-sub Change Request Memo (Abbreviated GFE) FINAL.docx Justification for No Material/Nonsubstantive Change
CMS-10791_Supporting Statement_112022.docx Supporting Statement A
CMS-10791_Supporting Statement_112022.docx Supporting Statement A
Patient-Provider Selected Dispute Resolution Entity Recertification
Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction
Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Form and Instruction
Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices Instruction
Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction
Notice of Right to Good Faith Estimate – Individual Physician Practitioners Form and Instruction
Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction
Notice of Right to Good Faith Estimate – Health Care Facilities Form and Instruction

All Historical Document Collections

202303-0938-013 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-03-29
202303-0938-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-03-21
202211-0938-008 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-11-15
202204-0938-013 Approved with change	New collection (Request for a new OMB Control Number)	2022-04-29