Information Collection Request

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

ICR 202207-1210-003 · OMB 1210-0150 · Historical Inactive

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form EBSA Form 700 Eligible Organization Self-Certification Form Modified Available
1210-0150 Contraception SS 2-1-23 (clean).docx Supporting Statement A Uploaded 2023-02-02 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
258164 Notice of Revocation of Accommodation New
228285 Confirmation Eligibility for the Individual Contraceptive Agreement Other-Model Modified
228284 Notice of Availability of Separate Payments for Contraceptive Services Other-Model Modified
205659 Self-Certification or Notification Form ModifiedEligible Organization Self-Certification
205659 Self-Certification or Notification Other-Model Notice Modified

ICR Details

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table that charts list comparision
  Inventory as of this Action Requested Previously Approved
11/30/2024 36 Months From Approved 01/31/2025
777,363 0 777,363
181 0 181
194,963 0 194,963





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table that charts list of burden
IC Title Form No. Form Name
Notice of Availability of Separate Payments for Contraceptive Services
Confirmation Eligibility for the Individual Contraceptive Agreement
Notice of Revocation of Accommodation
Self-Certification or Notification EBSA Form 700



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  No