Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Model Notice to HHS Removed 0 0 0 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 5 4 1 Form and Instruction CMS-10653
Total burden requested under this ICR: 595312 72 151209  
To view an IC, click on IC Title