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 Modified 0 0 0 Other-Document Removed
Federal IDR Process for Air Ambulance Services Modified 0 0 0 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-Notice of Offer Data Elements
Other-IDR Initiation Webform
Other-IDR Entity Selection Response Webform
Other-Notice of IDR Initiation Response
Other-ON Notice Response
Other-Withdrawal Notice
Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities and Providers of Air Ambulance Services Modified 1085700 1568963 11141820 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-Notice of Offer Data Elements
Other-IDR Initiation Webform
Other-IDR Entity Selection Response Webform
Other-Notice of IDR Initiation Response
Other-Notice of Open Negotiation Response
Other-Withdrawal Notice
IDR Entity Certification and IDR Entity Monthly Reporting Modified 43 0 7306 Other-IDR Certification Application
Other-Notice of Petition for Denial or Revocation
Other-Monthly IDR Entity Reporting Requirements
Other-Certified IDR Entity Written Determination
Registration of Group Health Plans and Health Insurance Issuers New 426 2025 0 Other-Health Plan Registry Instrument
Request of Extension of Time Periods for Extenuating Circumstances Modified 5 1 0 Other-Request of Extension of Time Periods for Extenuating Circumstances
Other-Request for Extension Notice
Total burden requested under this ICR: 1086174 1570989 11149126  
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