Model 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⚠️ Notice: This information collection may be referencing outdated material.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 Model Notice to HHS Form and Instruction
CMS-10653 Model Notice to HHS CMS-10653 Model Notice to HHS .pdf Form and Instruction
CMS-10653 Model Notice to HHS CMS-10653 Model Notice to HHS .pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Model Notice to HHS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.131(c)(4)

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	Model Notice to HHS	CMS-10653 Model Notice to HHS .pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 109	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: 54 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-182,051	182,051
Annual IC Time Burden (Hours)	-109	109
Annual IC Cost Burden (Dollars)	-45,513	45,513

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.