Information Collection Request

Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)

ICR 201710-0938-006 · OMB 0938-1344 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10653 Model Notice to HHS Form and Instruction New Available
Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction New Available
Form CMS-10653 Self-Certification & Notice to HHS Form and Instruction New Available
CMS-10653 - Emergency Clearance of the Paperwork Reduction Act Package.pdf Supplementary Document Uploaded 2017-10-10 Available
CMS-10653 Supporting Statement 10-2-17 clean.docx Supporting Statement A Uploaded 2017-10-06 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
228593 Model Notice to HHS Form and Instruction New
228592 Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction New
228591 Self-Certification & Notice to HHS Form and Instruction New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2018 6 Months From Approved
274,675 0 0
181 0 0
0 0 0





table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 274,675 0 274,675 0 0 0
Annual Time Burden (Hours) 181 0 181 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No