View RCF - Agency Submission

Title: Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in

Type of RCF: RCF New

Description of Agency Usage: DOL will be using the model notice, Provider Disclosure on Patient Protections Against Balance Billing - Facilities and Providers, for ERISA covered plans.

Authorizing Statute(s): None

Annual Cost to Federal Government: $0
Agency Contact: James Butikofer 202 693-8434 Butikofer.James@dol.gov

Common Form Information Collections (IC) in this RCF:

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name

RCF Summary of Burden:

	Total Request	Change Due to New Statute
Annual Number of Responses	10,367,171	10,367,171
Annual Time Burden (Hours)	463,193	463,193
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection of information.

202109-1210-001CF