Notice of Availability of Separate Payments for Contraceptive Services

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

Documents and Forms

Document Name Document Type
Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction
CMS-10653 Notice of Availability of Separate Payments for Contrace CMS-10653 Notice to enrollees 10-4-22.pdf Form and Instruction
CMS-10653 Notice of Availability of Separate Payments for Contrace CMS-10653 Notice to enrollees 10-4-22.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Notice of Availability of Separate Payments for Contraceptive Services	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.131(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10653	Notice of Availability of Separate Payments for Contraceptive Services	CMS-10653 Notice to enrollees 10-4-22.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 109	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: 54 %

	Requested	Previously Approved
Annual Number of Responses for this IC	595,307	595,307
Annual IC Time Burden (Hours)	68	68
Annual IC Cost Burden (Dollars)	151,208	151,208

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.