Self-Certification or Notification

Coverage of Certain Preventive Services under the Affordable Care Act—Private Sector

OMB: 1210-0150

IC ID: 205659

Information Collection (IC) Details

View Information Collection (IC)

Self-Certification or Notification
 
No Modified
 
Required to Obtain or Retain Benefits
 
29 CFR 2510.3-16 29 CFR 2590.715-2713A

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Notice CMS-10653 Model Notice to HHS_clean.docx Yes Yes Printable Only
Form EBSA Form 700 Eligible Organization Self-Certification CMS-10653 Certification_clean.docx http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf Yes No Printable Only

Health Health Care Services

 

5 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   58 %

  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 5 0 0 0 0 5
Annual IC Time Burden (Hours) 4 0 0 0 0 4
Annual IC Cost Burden (Dollars) 2 0 0 1 0 1

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