Information Collection Request
Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)
ICR 202302-0938-002 · OMB 0938-1344 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1344 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services |
Form and Instruction | Modified | Repair queued |
| Form CMS-10653 Self-Certification & Notice to HHS |
Form and Instruction | Modified | Repair queued |
 CMS-10653 Summary of Changes 1-24-2023.pdf |
Supplementary Document | Uploaded 2023-02-02 | Repair queued |
 CMS-10653 Supporting statement 60d-f.docx |
Supporting Statement A | Uploaded 2023-02-02 | Repair queued |
| CMS-10653 Appendix I - Notice-Issuer-Third-Party-Employer-Preventive.pdf |
Supplementary Document | Uploaded 2023-02-02 | Repair queued |
| CMS-10653 Model Notice to HHS_rev 9-14-22.pdf |
Supplementary Document | Uploaded 2023-02-02 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 258215 |  Confirmation of Eligibility for the Individual Contraceptive Arrangement |
Other-Model Attestation | New | |
| 228592 | Notice of Availability of Separate Payments for Contraceptive Services |
Form and Instruction | Modified | |
| 228591 | Self-Certification & Notice to HHS |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-1344 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202111-0938-010 |
| Agency Tracking No | CCIIO |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |