Self-Certification or Notiffication

Coverage of Certain Preventive Services Under the Affordable Care Act

OMB: 1210-0150

IC ID: 205659

Information Collection (IC) Details

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Self-Certification or Notiffication
 
No Modified
 
Required to Obtain or Retain Benefits
 
29 CFR 2510 29 CFR 2590

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Notice Model Notice 2014-08-20.docx Yes Yes Fillable Printable
Form EBSA Form 700 Eligible Organization Self-Certification EBSA Form 700.doc http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf Yes No Printable Only

Health Health Care Services

 

122 120
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   50 %

  Approved 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 122 0 1 119 0 2
Annual IC Time Burden (Hours) 51 0 1 48 0 2
Annual IC Cost Burden (Dollars) 33 0 0 32 0 1

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

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