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 Modified 511748 755658 52172709 Form and Instruction CMS-10791
Notice of Right to Good Faith Estimate – Health Care Facilities Modified 245336 1840020 194499927 Form and Instruction CMS-10791
Notice of Right to Good Faith Estimate – Individual Physician Practitioners Modified 145887 481426 75076368 Form and Instruction CMS-10791
Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices Modified 120525 421837 50649426 Instruction
Patient-Provider Selected Dispute Resolution Entity Recertification Unchanged 1 3 257
Total burden requested under this ICR: 1023497 3498944 372398687  
To view an IC, click on IC Title