Form CMS-10430 Model_Election_Exemption

Model HIPAA Exemption Election/Election Renewal Document for Plan Years Beginning
On or After September 23, 2010
The following may be submitted on plan sponsor’s or plan administrator’s letterhead:
Name of Plan: ___________________________
Plan Sponsor: ___________________________
Address: ___________________________ (Not applicable if election document is on letterhead
showing the plan sponsor’s address.)
EIN: ____________ Plan Number: (if applicable)
Plan Year/Period of Plan coverage: (beginning date) through (ending date)
(may reflect multiple plan years governed by a collective bargaining agreement ratified on or
after March 23, 2010.)
Plan Administrator:
Address: (If different from plan sponsor’s)
(Name of plan, or portion of plan that is self-funded) is not provided through insurance. (Plan
sponsor) elects under authority of section 2722(a)(2) of the Public Health Service (PHS) Act, and
45 CFR 146.180 of Federal regulations, to exempt (name of plan or self-funded portion) from the
following requirements of title XXVII of the PHS Act (list any or all of the following
requirements):
1. Standards related to benefits for mothers and newborns.
2. Parity in the application of certain limits to mental health benefits.
3. Required coverage for reconstructive surgery following mastectomies.
4. Coverage of dependent students on medically necessary leave of absence.
This election has been made in conformity with all rules of the plan sponsor, including any
public hearing, if required. I certify that the undersigned is authorized to submit this election on
behalf of (name of plan). A copy of the notice to plan enrollees is enclosed. (In the case of an
election renewal, in lieu of enclosing a copy of an updated notice to plan enrollees, the plan
sponsor may include a statement that the notice has been, or will be, provided to plan enrollees in
accordance with 45 CFR 146.180(f).) If CMS has any questions regarding this election, please
contact (name) at (phone number).
Signature
Title