Information Collection

Confirmation Eligibility for the Individual Contraceptive Agreement

IC 228285 under ICR 202207-1210-003 · OMB 1210-0150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0150 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22.docx	Other-Model
CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22.docx	Other-Model

IC Title:

Confirmation Eligibility for the Individual Contraceptive Agreement

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 2510.3-16 29 CFR 2590.715-2713A

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model			CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 58 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	31,600	-150,451	182,051
Annual IC Time Burden (Hours)	2,633	2,524	109
Annual IC Cost Burden (Dollars)	0	-45,658	45,658

Documents for IC

table that charts IC Documents
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.