View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
 
Yes Modified
 
Mandatory
 
29 CFR 2590

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Notice of Open Negotiation Yes Yes Fillable Printable
Other-Notice of IDR Initiation Yes Yes Fillable Printable
Other-Notice of Certified IDR Entity Selection Yes Yes Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate Yes Yes Fillable Printable
Other-Payment Settlement Form Yes Yes Fillable Printable
Other-Notice of Offer Data Elements Yes Yes Fillable Printable
Other-IDR Initiation Webform Yes Yes Fillable Fileable
Other-IDR Entity Selection Response Webform Yes Yes Fillable Fileable

Income Security General Retirement and Disability

 

17,435 15,168
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   95 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 27,649 0 0 0 0 27,649
Annual IC Time Burden (Hours) 54,517 0 0 0 0 54,517
Annual IC Cost Burden (Dollars) 426,742 0 0 0 0 426,742

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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