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

View Information Collection (IC)

Federal IDR Process for Air Ambulance Services
 
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-Good Faith Estimate Template Notice Yes Yes Fillable Printable
Other- PPDR Data Elements for Patients and Providers Yes Yes Fillable Printable
Other-Vendor Management Data Elements Yes Yes Fillable Printable
Other-Payment Settlement Form Notice Yes Yes Fillable Printable
Other-Notice of Offer Data Elements Yes Yes Fillable Printable

Income Security General Retirement and Disability

 

2,484 2,161
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 4,560 0 0 63 0 4,497
Annual IC Time Burden (Hours) 6,835 0 0 286 0 6,549
Annual IC Cost Burden (Dollars) 56,825 0 0 39,822 0 17,003

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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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