Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities

No Surprises Act: IDR Process

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1210-0169 can be found here:

Document [pdf]

Download: pdf | pdf

File Type	application/pdf
File Title	Good Faith Estimate Template
File Modified	2021-12-20
File Created	2021-12-10