OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Mental Health and Substance Abuse Disorder Parity Disclosure Request, Model Notice

IC 227109 under ICR 202405-1210-001 · OMB 1210-0138.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Model disclosure template - FINAL.docx Other-Model Notice
Model disclosure template - FINAL.docx Other-Model Notice
Arabic (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Arabic)
Arabic (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Arabic)
Chinese (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Chinese)
Chinese (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Chinese)
French (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (French)
French (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (French)
Korean (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Korean)
Korean (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Korean)
Spanish (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Spanish)
Spanish (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Spanish)
Tagalog (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Tagalog)
Tagalog (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Tagalog)
Vietnamese (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Vietnamese)
Vietnamese (clean)- MHPAEA Model Disclosure Template.docx Other-Model Notice (Vietnamese)
Model Disclosure template compare ROCISed and Final redline 9-3-2019 (002).docx
Model Disclosure Template - Track Changes Version		IC Document
Model Disclosure template compare ROCISed and Final redline 9-3-2019 (002).docx
Model Disclosure Template - Track Changes Version		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 Notice Model disclosure template - FINAL.docx Yes No Fillable Printable
Other-Model Notice (Arabic) Arabic (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Chinese) Chinese (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (French) French (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Korean) Korean (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Spanish) Spanish (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Tagalog) Tagalog (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Vietnamese) Vietnamese (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved 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 249,008 0 0 0 0 249,008
Annual IC Time Burden (Hours) 20,751 0 0 0 0 20,751
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Model Disclosure Template - Track Changes Version Model Disclosure template compare ROCISed and Final redline 9-3-2019 (002).docx 09/03/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.