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-Disclosure Requirement
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-Good Faith Estimate Template Notice
Other- PPDR Data Elements for Patients and Providers
Other-Vendor Management Data Elements
Other-PPDR Dispute Initiation Form
Other-Online PPDR Initiation Form
Other-Payment Settlement Form Notice
Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities Modified 2755000 1691250 58508140 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-Notice of Offer Data Elements
Other-IDR Initiation Webform
Other-IDR Entity Selection Response Webform
Other-Good Faith Estimate Template Notice
Other-PPDR Data Elements for Patients and Providers
Other-Online PPDR Initiation Form
Other-PPDR Dispute Initiation Form
Other-Vendor Management Data Elements
IDR Entity Certification and IDR Entity Monthly Reporting Modified 43 0 9892 Other-IDR Certification Application
Other-Notice of Petition for Denial or Revocation
Other-Monthly IDR Entity Reporting Requirements
Other-Certified IDR Entity Written Determination
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
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: 2755048 1691251 58518032  
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