Patient Protection and Affordable Care Act Patient Protection Notice

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0142 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Patient Protection and Affordable Care Act Patient Protection Notice	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.715-2719A

Information Collection Instruments:

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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28,272	Number of Respondents for Small Entity: 27,355

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

Percentage of Respondents Reporting Electronically: 58 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	128,133	-606,667	734,800
Annual IC Time Burden (Hours)	3,534	-3,012	6,546
Annual IC Cost Burden (Dollars)	1,602	-2,403	4,005

Documents for IC

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