Confirmation of Eligibility for the Individual Contraceptive Arrangement

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

Documents and Forms

Document Name Document Type
CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22.pdf Other-Model Attestation
CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22.pdf Other-Model Attestation

Information Collection (IC) Details

IC Title:	Confirmation of Eligibility for the Individual Contraceptive Arrangement	Agency IC Tracking Number:	CCIIO -10653

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.131(a)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Attestation			CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 63,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	63,200	63,200
Annual IC Time Burden (Hours)	5,267	5,267
Annual IC Cost Burden (Dollars)	0	0

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.