Mental Health and Substance Abuse Disorder Parity Disclosure Request, Model Notice

Mental Health Parity and Addiction Equity Act of 2008 Notices

OMB: 1210-0138

IC ID: 227109

Documents and Forms
Document Name
Document Type
Other-Model Notice
Other-Model Notice (Arabic)
Other-Model Notice (Chinese)
Other-Model Notice (French)
Other-Model Notice (Korean)
Other-Model Notice (Spanish)
Other-Model Notice (Tagalog)
Other-Model Notice (Vietnamese)
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Mental Health and Substance Abuse Disorder Parity Disclosure Request, Model Notice
 
No Modified
 
Voluntary
 
29 CFR 2590.712(d)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Notice Model disclosure template - FINAL.docx Yes No Fillable Printable
Other-Model Notice (Arabic) Arabic (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Chinese) Chinese (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (French) French (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Korean) Korean (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Spanish) Spanish (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Tagalog) Tagalog (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable
Other-Model Notice (Vietnamese) Vietnamese (clean)- MHPAEA Model Disclosure Template.docx Yes No Fillable Printable

Health Health Care Services

 

249,008 231,557
   
Individuals or Households
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 249,008 0 0 0 0 249,008
Annual IC Time Burden (Hours) 20,751 0 0 0 0 20,751
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Model Disclosure Template - Track Changes Version Model Disclosure template compare ROCISed and Final redline 9-3-2019 (002).docx 09/03/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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