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
Confirmation of Eligibility for the Individual Contraceptive Arrangement
New
63200
5267
0
Other-Model Attestation
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
5
4
1
Form and Instruction
CMS-10653
EBSA FORM 700 - Certification Form
Total burden requested under this ICR:
658512
5339
151209
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