Complaints Submission Process under the No Surprises Act (CMS-10779)

OMB 0938-1406

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10779 Complaints Related to Surprise Billing Form and Instruction
CMS-10779 Appendix V - Comment Response Summary_6.7.22.docx Supplementary Document
CMS-10779 Supporting Statement 30d final_Clean.docx Supporting Statement A
Complaints Related to Surprise Billing Form and Instruction

All Historical Document Collections

202206-0938-005 Approved with change	Extension without change of a currently approved collection	2022-06-07
202108-0938-011 Approved with change	New collection (Request for a new OMB Control Number)	2021-11-24