Self-Certification or Notification

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

Documents and Forms

Document Name Document Type
CMS-10653 Model Notice to HHS_rev 9-14-22.docx Other-Model Notice
CMS-10653 Model Notice to HHS_rev 9-14-22.docx Other-Model Notice
EBSA Form 700 Eligible Organization Self-Certification CMS-10653 Certification_rev 2-2-23.docx www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf Form
EBSA Form 700 Eligible Organization Self-Certification CMS-10653 Certification_rev 2-2-23.docx www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf Form

Information Collection (IC) Details

IC Title:	Self-Certification or Notification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590.715-2713A 29 CFR 2510.3-16

Information Collection Instruments:

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_rev 9-14-22.docx		Yes	Yes	Printable Only
Form	EBSA Form 700	Eligible Organization Self-Certification	CMS-10653 Certification_rev 2-2-23.docx	http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	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: 58 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2	-3	5
Annual IC Time Burden (Hours)	2	-2	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.