Affordable Care Act Patient Protection Notice

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0142 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Affordable Care Act Patient Protection Notice	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.715-2719A

Information Collection Instruments:

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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 261,680	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: 38 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	6,186,404	6,186,404
Annual IC Time Burden (Hours)	33,000	33,000
Annual IC Cost Burden (Dollars)	48,000	48,000

Documents for IC

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