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

View Information Collection (IC)

Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process
 
No New
 
Mandatory
 
45 CFR 149.620

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction cms-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Printable
Form and Instruction CMS-10853 Yes No Fillable Printable
Form and Instruction CMS-10853 Yes No Fillable Printable
Form and Instruction CMS-10853 Yes No Fillable Printable
Form and Instruction CMS-10853 Yes No Fillable Printable
Form and Instruction CMS-10853 Yes No Fillable Printable
Form and Instruction CMS-10853 Yes No Fillable Printable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction cms-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction cms-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction cms-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes Yes Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-10853 Yes No Fillable Fileable
Form and Instruction CMS-108i53 Yes No Fillable Fileable

Health Health Care Services

 

26,659 0
   
Individuals or Households
 
   35 %

  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 26,659 26,659 0 0 0 0
Annual IC Time Burden (Hours) 322,189 322,189 0 0 0 0
Annual IC Cost Burden (Dollars) 32,112,898 32,112,898 0 0 0 0

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