Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Federal IDR Process for Air Ambulance Services Modified 4497 7825 69403 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 13743 8383 291861 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 85 0 19554 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 13 3 0 Other-Request of Extension of Time Periods for Extenuating Circumstances
Other-Request for Extension Notice
Total burden requested under this ICR: 18338 16211 380818  
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