PRA IC List
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Agenda
Reg Review
ICR
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
Model Notice to HHS
Notice of Availability of Separate Payments for Contraceptive Services
Modified
595307
68
151208
Form and Instruction
CMS-10653
Notice of Availability of Separate Payments for Contraceptive Services
Self-Certification & Notice to HHS
Modified
9
4
2
Form and Instruction
CMS-10653
EBSA FORM 700 - Certification Form
Total burden requested under this ICR:
777367
181
196723
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