Self-Certification

Coverage of Certain Preventive Services Under the Affordable Care Act

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0150 can be found here:

Documents and Forms

Document Name Document Type
Form EBSA700 Self-Certification Form
EBSA700 Preventive Health Services Certification Preventive Service Certification 1-30-13.docx Form

Information Collection (IC) Details

IC Title:	Self-Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	EBSA700	Preventive Health Services Certification	Preventive Service Certification 1-30-13.docx	xxx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Certification	FR Citation: 78 FR 8833

Number of Respondents: 1	Number of Respondents for Small Entity: 1

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.