Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)

ICR 202302-0938-002

OMB: 0938-1344

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction	Modified
Form CMS-10653 Self-Certification & Notice to HHS Form and Instruction	Modified
CMS-10653 Summary of Changes 1-24-2023.pdf Supplementary Document	2023-02-02
CMS-10653 Supporting statement 60d-f.docx Supporting Statement A	2023-02-02
CMS-10653 Appendix I - Notice-Issuer-Third-Party-Employer-Preventive.pdf Supplementary Document	2023-02-02
CMS-10653 Model Notice to HHS_rev 9-14-22.pdf Supplementary Document	2023-02-02

IC Document Collections

IC ID	Document Title	Status
258215	Confirmation of Eligibility for the Individual Contraceptive Arrangement Other-Model Attestation	New
228592	Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction	Modified
228591	Self-Certification & Notice to HHS Form and Instruction	Modified