Notice of Availability of Separate Payments for Contraceptive Services

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

OMB: 0938-1344

IC ID: 228592

Information Collection (IC) Details

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Notice of Availability of Separate Payments for Contraceptive Services
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR 147.131(f)

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 to enrollees (Notice of Availability).pdf Yes Yes Fillable Fileable

Health Health Care Services

 

109 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   54 %

  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 595,307 0 0 0 0 595,307
Annual IC Time Burden (Hours) 68 0 0 0 0 68
Annual IC Cost Burden (Dollars) 151,208 0 0 0 0 151,208

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