Information Collection

Confirmation of Eligibility for the Individual Contraceptive Arrangement

IC 258215 under ICR 202302-0938-002 · OMB 0938-1344.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1344 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.