Patient Protection and Affordable Care Act Patient Protection Notice

OMB 1210-0142

The Patient Protection Notice is used by health plan sponsors and issuers to notify certain individuals of their right to (1) choose a primary care provider or a pediatrician when a plan or issuer requires participants or subscribers to designate a primary care physician; or (2) obtain obstetrical or gynecological care without prior authorization.

The latest form for Patient Protection and Affordable Care Act Patient Protection Notice expires 2022-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
1210-0142 EBSA ACA Patient Protection ss22 3-8-2022.docx Supporting Statement A
No-Surprises-Act.pdf Supplementary Document
Patient Protection and Affordable Care Act Patient Protection Notice

All Historical Document Collections

202202-1210-003 Approved without change	Extension without change of a currently approved collection	2022-03-15
202108-1210-006 Approved with change	Revision of a currently approved collection	2021-08-24
202106-1210-002 Improperly submitted and continue	Revision of a currently approved collection	2021-07-13
201902-1210-004 Approved without change	Extension without change of a currently approved collection	2019-04-01
201510-1210-004 Approved without change	Revision of a currently approved collection	2015-11-18
201401-1210-003 Approved without change	Extension without change of a currently approved collection	2014-02-28
201011-1210-009 Approved without change	Extension without change of a currently approved collection	2010-12-28
201009-1210-005 Approved without change	Revision of a currently approved collection	2010-09-30
201006-1210-003 Preapproved	New collection (Request for a new OMB Control Number)	2010-06-18