Information Collection

Individual Notice of Preexisting Condition Exclusion under Group Health Plans

IC 45340 under ICR 200608-1210-002 · OMB 1210-0102.

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Information Collection (IC) Details

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IC Title:	Individual Notice of Preexisting Condition Exclusion under Group Health Plans	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.701-4 29 CFR 2590.701-3

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 747,914	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,261,852	1,261,852
Annual IC Time Burden (Hours)	3,786	3,786
Annual IC Cost Burden (Dollars)	763,841	763,841

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.