Self-Certification

Coverage of Certain Preventive Services Under the Affordable Care Act

OMB: 1210-0150

IC ID: 205659

Information Collection (IC) Details

View Information Collection (IC)

Self-Certification
 
No New
 
Required to Obtain or Retain Benefits
 
29 CFR 2590

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form EBSA700 Preventive Health Services Certification Preventive Service Certification 1-30-13.docx xxx Yes No Printable Only

Health Health Care Services

Certification  78 FR 8833

1 1
   
Private Sector Not-for-profit institutions
 
   50 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1 0 1 0 0 0
Annual IC Time Burden (Hours) 1 0 1 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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