OMB control number

Patient Protection and Affordable Care Act Patient Protection Notice

OMB 1210-0142 · DOL/EBSA.

OMB 1210-0142

The Patient Protection Notice is used by health plan sponsors and issuers to notify certain individuals of their right to (1) choose a primary care provider or a pediatrician when a plan or issuer requires participants or subscribers to designate a primary care physician; or (2) obtain obstetrical or gynecological care without prior authorization.

The latest form for Patient Protection and Affordable Care Act Patient Protection Notice expires 2022-05-31 and is listed under ICR 201902-1210-004.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
1210-0142 EBSA ACA Patient Protection ss22 3-8-2022.docx	Supporting Statement A
No-Surprises-Act.pdf	Supplementary Document
Patient Protection and Affordable Care Act Patient Protection Notice	Information collection

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202202-1210-003	Extension without change of a currently approved collection	2022-03-15	Approved without change
202108-1210-006	Revision of a currently approved collection	2021-08-24	Approved with change
202106-1210-002	Revision of a currently approved collection	2021-07-13	Improperly submitted and continue
201902-1210-004	Extension without change of a currently approved collection	2019-04-01	Approved without change
201510-1210-004	Revision of a currently approved collection	2015-11-18	Approved without change
201401-1210-003	Extension without change of a currently approved collection	2014-02-28	Approved without change
201011-1210-009	Extension without change of a currently approved collection	2010-12-28	Approved without change
201009-1210-005	Revision of a currently approved collection	2010-09-30	Approved without change
201006-1210-003	New collection (Request for a new OMB Control Number)	2010-06-18	Preapproved