Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Good Faith Estimates of Expected Charges Upon Request of Uninsured Individuals for Scheduled Items and Services Unchanged 3498942 3498942 356717137 Form and Instruction CMS-10791 Right to Receive a Good Faith Estimate of Expected Charges Notice
Notice of Right to Good Faith Estimate – Health Care Facilities Modified 245336 1840020 194499927 Form and Instruction CMS-10791 Good Faith Estimates Template and Instructions
Notice of Right to Good Faith Estimate – Individual Physician Practitioners Unchanged 145887 481426 75076368 Form and Instruction CMS-10791 Right to Receive a Good Faith Estimate of Expected Charges Notice
Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices Unchanged 120525 421837 50649426 Instruction
Patient-Provider Selected Dispute Resolution Entity Recertification Unchanged 1 3 257
Total burden requested under this ICR: 4010691 6242228 676943115  
To view an IC, click on IC Title