Information Collection

Notice of Availability of Separate Payments for Contraceptive Services

IC 228592 under ICR 201804-0938-006 · OMB 0938-1344.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1344 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction
CMS-10653 Notice of Availability of Separate Payments for Contrace CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services (2018).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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: 45 CFR 147.131(f)

Information Collection Instruments:

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 Notice of Availability of Separate Payments for Contraceptive Services (2018).pdf		Yes	Yes	Fillable Fileable

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

Percentage of Respondents Reporting Electronically: 54 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	595,307	385,042	210,265
Annual IC Time Burden (Hours)	68	0	68
Annual IC Cost Burden (Dollars)	151,208	151,208	0

Documents for IC

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.