Self-Certification or Notification

Coverage of Certain Preventive Services Under the Affordable Care Act-For-Profit Entities

OMB: 1210-0152

IC ID: 212710

Information Collection (IC) Details

View Information Collection (IC)

Self-Certification or Notification
 
No New
 
Required to Obtain or Retain Benefits
 
29 CFR 2510

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form EBSA Form 700 Eligible Organization Self-Certification EBSA Form 700.doc http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf Yes No Printable Only
Other-Model Notice Model Notice 8 14 14.doc Yes Yes Fillable Printable

Health Health Care Services

 

71 0
   
Private Sector Businesses or other for-profits
 
   0 %

  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 71 0 71 0 0 0
Annual IC Time Burden (Hours) 30 0 30 0 0 0
Annual IC Cost Burden (Dollars) 19 0 19 0 0 0

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