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Request of Extension of Time Periods for Extenuating Circumstances
No Surprises Act: IDR Process
CMS-10791 - Appendix 13 Request for Extension Notice
Request of Extension of Time Periods for Extenuating Circumstances
OMB: 1210-0169
OMB.report
DOL/EBSA
OMB 1210-0169
ICR 202302-1210-003
IC 252197
Request of Extension of Time Periods for Extenuating Circumstances
( )
⚠️ Notice: This form may be outdated.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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13. Appendix 14-Request for Extension
File Modified
2021-12-20
File Created
2021-12-13
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