Form CMS-10653 Certification Form

OMB Control No. 0938-NEW
Expiration Date: XX/2020

EBSA FORM 700-- CERTIFICATION
(revised September 2017)
Public Health Service Act section 2713 requires, among other things, that certain group health
plans and issuers provide benefits for women’s preventive services without cost sharing as
provided for in comprehensive guidelines supported by the Health Resources Services
Administration (HRSA). The HRSA Guidelines provide an exemption for group health plans and
student health insurance coverage established or maintained by entities that object to providing
coverage for all or a subset of contraceptive services based on religious beliefs or moral
convictions. However, an optional accommodation process is available for objecting entities that
are exempt but choose to shift the otherwise applicable obligation to provide benefits for
contraceptive services to its issuer or third party administrator. Objecting entities should note that
if their issuer has their own religious or moral objection to providing contraception services, an
issuer may also avail themselves of the exemption. Separately, third party administrators with an
objection may also decline to enter or continue contracts as a third party administrator of the plan.
This form may, but is not required to, be used by an objecting entity to provide notice to its issuer
or third party administrator that that the objecting entity has a sincerely held religious or moral
objection to coverage of all or a subset of contraceptive services, pursuant to 26 CFR 54.98152713A, 29 CFR 2590.715-2713A, and 45 CFR 147.131. Alternatively, an objecting entity may
also provide notice to the Secretary of Health and Human Services. A model notice is available at
- http://www.cms.gov/cciio/resources/Regulations-and-Guidance/index.html#Prevention.
An organization may revoke its use of the accommodation process at a later date if it chooses to do
so provided that written notice of any such revocation is given to participants and beneficiaries
consistent with guidance issued by the Secretaries of Labor and Health and Human Services.
If you intend to utilize the optional accommodation process, please fill out this form completely
and provide it to your plan’s health insurance issuers (for insured coverage) or third party
administrators (for self-insured coverage). 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 entity

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

I certify the organization is an objecting entity (as described in 26 CFR 54.9815-2713A(a), 29
CFR 2590.715-2713A(a); 45 CFR 147.131(c)) that has a sincerely held religious or moral
objection to providing coverage for some or all of any contraceptive services.

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

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.

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-NEW. 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.