Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Disclosure for Self-Insured Plans Opting-in to State Law Unchanged 28 42 0 Other-Model Notice
Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities Unchanged 3801675 739158 0 Form and Instruction CMS-10780 Standard Notice and Consent
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 Unchanged 1627046 2086326 0 Form and Instruction CMS-10780 Standard Notice and Consent
Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden Unchanged 2440565 1830424 0 Form and Instruction CMS-10780 Standard Notice and Consent
Plan and Issuer Disclosure on Patient Protections Against Balance Billing Unchanged 16933056 187285 0 Other-Model Notice
Provider Disclosure on Patient Protections Against Balance Billing - Facilities and Providers Unchanged 33868513 19824 0 Other-Model Notice
Provider Disclosure on Patient Protections Against Balance Billing - States Unchanged 11 33 0 Other-Model Notice
Title: Provider Disclosure on Patient Protections Against Balance Billing – Facility and Provider Agreements Unchanged 5822 23288 0 Other-Model Notice
Total burden requested under this ICR: 58676716 4886380 0  
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