Information Collection

Mental Health and Substance Abuse Disorder Parity Disclosure Request, Model Notice

IC 227109 under ICR 201706-1210-001 · OMB 1210-0138.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0138 can be found here:

Documents and Forms

Document Name Document Type
Model disclosure template - FINAL.docx Other-Model Notice
Model Disclosure template compare ROCISed and Final redline 9-3-2019 (002).docx Model Disclosure Template - Track Changes Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Mental Health and Substance Abuse Disorder Parity Disclosure Request, Model Notice	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 2590.712(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			Model disclosure template - FINAL.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 249,008	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	249,008	249,008
Annual IC Time Burden (Hours)	20,751	20,751
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Model Disclosure Template - Track Changes Version	Model Disclosure template compare ROCISed and Final redline 9-3-2019 (002).docx	09/03/2019

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