Self-Certification & Notice to HHS

Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)

OMB: 0938-1344

IC ID: 228591

Information Collection (IC) Details

View Information Collection (IC)

Self-Certification & Notice to HHS
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR 147.131(c)(3)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10653 EBSA FORM 700 - Certification Form CMS-10653 Certification_rev 1-24-23.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

5 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5 0 0 0 0 5
Annual IC Time Burden (Hours) 4 0 0 0 0 4
Annual IC Cost Burden (Dollars) 1 0 0 0 0 1

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