Contraceptive Disclosure

Transparency in Pricing Information (CMS-10715)

Documents and Forms

Document Name Document Type
Form CMS-10715 Contraceptive Disclosure Form and Instruction
CMS-10715 Transparency in Coverage 45 CFR 147212 - Transparency in Coverage.docx Form and Instruction

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10715	Transparency in Coverage	45 CFR 147212 - Transparency in Coverage.docx		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 %

	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

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.