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

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10780 Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities Form and Instruction
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
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 - Facilities and Providers Form and Instruction
CMS-10780.Supporting Statement Part A (30-day).docx Supporting Statement A
Disclosure for Self-Insured Plans Opting-in to State Law Other-Model Notice
Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities Form and Instruction
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
Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers Form and Instruction
Plan and Issuer Disclosure on Patient Protections Against Balance Billing Other-Model Notice
Title: Provider Disclosure on Patient Protections Against Balance Billing – Facility and Provider Agreements Other-Model Notice
Provider Disclosure on Patient Protections Against Balance Billing - Facilities and Providers Other-Model Notice
Provider Disclosure on Patient Protections Against Balance Billing - States Other-Model Notice