Information Collection

Notice of Availability of Separate Payments for Contraceptive Services

IC 228284 under ICR 202407-1210-002 · OMB 1210-0150.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10653 Notice to enrollees.pdf	Other-Model
CMS-10653 Notice to enrollees.pdf	Other-Model

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590.715-2713A 29 CFR 2510.3-16

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					Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 55

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: 58 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	595,307	0	595,307
Annual IC Time Burden (Hours)	68	0	68
Annual IC Cost Burden (Dollars)	181,218	31,915	149,303

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.

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