Information Collection

Billing and Collection of the Separate Payment for Certain Contraceptive Services

IC 234036 under ICR 201811-0938-001 · OMB 0938-1358.

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Information Collection (IC) Details

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IC Title:	Billing and Collection of the Separate Payment for Certain Contraceptive Services	Agency IC Tracking Number:	10681

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,186	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 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	1,186	1,186
Annual IC Time Burden (Hours)	54,078	54,078
Annual IC Cost Burden (Dollars)	0	0

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