Confirmation Eligibility for the Individual Contraceptive Agreement

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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.