Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Model Notice to HHS New 64405 109 0 Form and Instruction CMS-10653
Notice of Availability of Separate Payments for Contraceptive Services New 210265 68 0 Form and Instruction CMS-10653
Self-Certification & Notice to HHS New 5 4 0 Form and Instruction CMS-10653
Total burden requested under this ICR: 274675 181 0  
To view an IC, click on IC Title