Information Collection

Contraceptive Disclosure

IC 271985 under ICR 202410-0938-023 · OMB 0938-1429.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1429 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10715 Contraceptive Disclosure	Form and Instruction
Form CMS-10715 Transparency in Coverage Contraceptive Disclosure	Form and Instruction
CMS-10715 Transparency in Coverage 45 CFR 147212 - Transparency in Coverage.docx	Form and Instruction
CMS-10715 Transparency in Coverage 45 CFR 147212 - Transparency in Coverage.docx	Form and Instruction

IC Title:

Contraceptive Disclosure

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 47 CFR 147.211(b)(1)(vi)

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
Form and Instruction	CMS-10715				Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 836

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: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	836	836
Annual IC Time Burden (Hours)	71,060	71,060
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.

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