Form CMS-10459 Self-Certification

EBSA FORM 700-- CERTIFICATION
(revised August 2014)
This form may be used to certify that the health coverage established or maintained or arranged by
the organization listed below qualifies for an accommodation with respect to the federal requirement
to cover certain contraceptive services without cost sharing, pursuant to 26 CFR 54.9815-2713A, 29
CFR 2590.715-2713A, and 45 CFR 147.131. Alternatively, an eligible organization may also
provide notice to the Secretary of Health and Human Services.
Please fill out this form completely. This form should be made available for examination upon
request and maintained on file for at least 6 years following the end of the last applicable plan year.
Name of the objecting organization

Name and title of the individual who
is authorized to make, and makes,
this certification on behalf of the
organization
Mailing and email addresses and
phone number for the individual
listed above

I certify the organization is an eligible organization (as described in 26 CFR 54.9815-2713A(a), 29
CFR 2590.715-2713A(a); 45 CFR 147.131(b)) that has a religious objection to providing coverage
for some or all of any contraceptive services that would otherwise be required to be covered.
Note: An organization that offers coverage through the same group health plan as a religious
employer (as defined in 45 CFR 147.131(a)) and/or an eligible organization (as defined in 26 CFR
54.9815-2713A(a); 29 CFR 2590.715-2713A(a); 45 CFR 147.131(b)), and that is part of the same
controlled group of corporations as, or under common control with, such employer and/or
organization (within the meaning of section 52(a) or (b) of the Internal Revenue Code), is considered
to meet the requirements of 26 CFR 54.9815-2713A(a)(3), 29 CFR 2590.715-2713A(a)(3), and 45
CFR 147.131(b)(3).
I declare that I have made this certification, and that, to the best of my knowledge and belief, it is
true and correct. I also declare that this certification is complete.

______________________________________
Signature of the individual listed above

______________________________________
Date

The organization or its plan using this form must provide a copy of this certification to the plan’s
health insurance issuer (for insured health plans) or a third party administrator (for self-insured health
plans) in order for the plan to be accommodated with respect to the contraceptive coverage
requirement.
Notice to Third Party Administrators of Self-Insured Health Plans
In the case of a group health plan that provides benefits on a self-insured basis, the provision of
this certification to a third party administrator for the plan that will process claims for
contraceptive coverage required under 26 CFR 54.9815-2713(a)(1)(iv) or 29 CFR 2590.7152713(a)(1)(iv) constitutes notice to the third party administrator that the eligible organization:
(1) Will not act as the plan administrator or claims administrator with respect to claims for
contraceptive services, or contribute to the funding of contraceptive services; and
(2) The obligations of the third party administrator are set forth in 26 CFR 54.9815-2713A, 29
CFR 2510.3-16, and 29 CFR 2590.715-2713A.
As an alternative to using this form, an eligible organization may provide notice to the Secretary of
Health and Human Services that the eligible organization has a religious objection to providing
coverage for all or a subset of contraceptive services, pursuant to 26 CFR 54.98152713A(b)(1)(ii)(B) and (c)(1)(ii), 29 CFR 2590.715-2713A(b)(1)(ii)(B) and (c)(1)(ii), and 45 CFR
147.131(c)(1)(ii). A model notice is available at: http://www.cms.gov/cciio/resources/Regulationsand-Guidance/index.html#Prevention.
This form or a notice to the Secretary is an instrument under which the plan is operated.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to average 50 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.