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No Surprises Act: IDR Process
Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment
OMB: 1210-0169
OMB.report
DOL/EBSA
OMB 1210-0169
ICR 202207-1210-004
IC 254938
Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment
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⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1210-0169 can be found here:
2023-11-03 - Revision of a currently approved collection
2023-02-24 - RCF Recertification
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File Type
application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author
Khan, Mariam - EBSA
File Modified
0000-00-00
File Created
2023-08-27
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