Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment Unchanged 127955 21326 0 Other-Disclosure Requirement
Federal IDR Process for Air Ambulance Services Modified 7879 13671 121598 Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-Notice of Certified IDR Entity Selection
Other-Notice of Agreement on an Out-of-Network Rate
Other-Good Faith Estimate Template Notice
Other- PPDR Data Elements for Patients and Providers
Other-Vendor Management Data Elements
Other-Payment Settlement Form Notice
Other-Notice of Offer Data Elements
Other-PPDR Dispute Initiation Form
Other-Online PPDR Initiation Form
Other-IDR Initiation Webform
Other-IDR Entity Selection Response Webform
Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities Modified 27649 54517 426742 Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-Notice of Certified IDR Entity Selection
Other- Notice of Agreement on an Out-of-Network Rate
Other-Payment Settlement Form
Other-Good Faith Estimate Template Notice
Other-PPDR Data Elements for Patients and Providers
Other-HHS Vendor Management
Other-Notice of Offer Data Elements
Other-PPDR Dispute Initiation Form
Other-Online PPDR Initiation Form
Other-IDR Initiation Webform
Other-IDR Entity Selection Response Webform
IDR Entity Certification and IDR Entity Monthly Reporting Modified 38 0 7807 Other-IDR Certification Application
Other-Notice of Petition for Denial or Revocation
Other-Monthly IDR Entity Reporting Requirements
Other-SDRE Determination Notice
Other-SDRE Confirmation of Receipt of Settlement Information
Other-SDRE Selection Notice
Other-SDRE Entity Certification Data Elements
Other-SDRE Declining Eligibility or Need More Information
Other-Certified IDR Entity Written Determination
Request of Extension of Time Periods for Extenuating Circumstances Unchanged 25 6 0 Other-Request of Extension of Time Periods for Extenuating Circumstances
Other-Request for Extension Notice
Total burden requested under this ICR: 163546 89520 556147  
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