Model Notice to HHS

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

OMB: 0938-1344

IC ID: 228593

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Model Notice to HHS
 
No New
 
Required to Obtain or Retain Benefits
 
45 CFR 147.131(c)(4)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services CMS-10653 Model Notice to HHS .pdf Yes Yes Fillable Fileable

Health Health Care Services

 

55 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   54 %

  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 64,405 64,405 0 0 0 0
Annual IC Time Burden (Hours) 109 109 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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