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 Name	Document 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)

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 2590.712(d)

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice	Yes	No	Fillable Printable
Other-Model Notice (Arabic)	Yes	No	Fillable Printable
Other-Model Notice (Chinese)	Yes	No	Fillable Printable
Other-Model Notice (French)	Yes	No	Fillable Printable
Other-Model Notice (Korean)	Yes	No	Fillable Printable
Other-Model Notice (Spanish)	Yes	No	Fillable Printable
Other-Model Notice (Tagalog)	Yes	No	Fillable Printable
Other-Model Notice (Vietnamese)	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 249,008

Number of Respondents for Small Entity: 231,557

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

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

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Model Disclosure Template - Track Changes Version		09/03/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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