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Federal forms, ICRs, and supporting documents

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Employer Notification Request to HHS of its Objection to Providing Contraceptive Services – Self-Certification

IC 212753 under ICR 201503-0938-004 · OMB 0938-1248.

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Document Type
IC Document
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Employer Notification Request to HHS of its Objection to Providing Contraceptive Services – Self-Certification
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR 147.131(b)(4) 45 CFR 147.131(c)(1)

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

Health Health Care Services

 

61 0
   
Private Sector Not-for-profit institutions
 
   0 %

  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 61 0 0 -61 0 122
Annual IC Time Burden (Hours) 51 0 0 -59 0 110
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Model Notice CMS-10535 Model Notice.pdf 03/06/2015
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.