Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Model Notice to HHS Modified 182051 109 45513 Form and Instruction CMS-10653
Notice of Availability of Separate Payments for Contraceptive Services Modified 595307 68 151208 Form and Instruction CMS-10653
Self-Certification & Notice to HHS Modified 9 4 2 Form and Instruction CMS-10653
Total burden requested under this ICR: 777367 181 196723  
To view an IC, click on IC Title