Information Collection

Individual Notice of Preexisting Condition Exclusion under Group Health Plans

IC 45340 under ICR 201211-1210-003 · 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: Modified

Obligation to Respond: Mandatory

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

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: 685,114	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	Previously Approved
Annual Number of Responses for this IC	575,411	-853,847	1,429,258
Annual IC Time Burden (Hours)	3,452	-836	4,288
Annual IC Cost Burden (Dollars)	731,390	-134,373	865,763

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