Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden

Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in (CMS-10780)

OMB: 0938-1401

IC ID: 249148

Documents and Forms

Document Name Document Type
Form CMS-10780 Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden Form and Instruction
CMS-10780 Standard Notice and Consent CMS-10780 - Standard Notice and Consent.pdf Form and Instruction