Self-Certification & Notice to HHS

Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)

⚠️ Notice: This information collection may be referencing outdated material.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 Self-Certification & Notice to HHS Form and Instruction
CMS-10653 EBSA FORM 700 - Certification Form CMS-10653 Certification.pdf Form and Instruction
CMS-10653 EBSA FORM 700 - Certification Form CMS-10653 Certification.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Self-Certification & Notice to HHS	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(c)(3)

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	EBSA FORM 700 - Certification Form	CMS-10653 Certification.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	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: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5	-4	9
Annual IC Time Burden (Hours)	4	0	4
Annual IC Cost Burden (Dollars)	1	-1	2

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.