Information Collection

Notice of Availability of Separate Payments for Contraceptive Services

IC 228284 under ICR 201803-1210-001 · OMB 1210-0150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0150 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DOL Notice to enrollees.docx	Other-Model

IC Title:

Notice of Availability of Separate Payments for Contraceptive Services

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590.715-2713A 29 CFR 2510.3-16

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model			DOL Notice to enrollees.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 109

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	595,307	385,062	210,245
Annual IC Time Burden (Hours)	68	0	68
Annual IC Cost Burden (Dollars)	151,595	99,030	52,565

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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