Form CMS-10653 EBSA FORM 700 - Certification Form

OMB Control Number: 0938-1344
Expiration Date: XX/XX/XXXX

EBSA FORM 700-- CERTIFICATION
(revised April 2018)
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 exemptions for group health plans and
student health insurance coverage under certain circumstances related to an objection to providing
contraception coverage. An accommodation process is also available for eligible entities, under
which the obligation to provide benefits for contraceptive services is shifted to its issuer or third
party administrator. The accommodation process is described in 26 CFR 54.9815-2713A, 29 CFR
2590.715-2713A, and 45 CFR 147.131. Different versions of these rules have been in place since
July 2015. These instructions and model notice may be used to claim an accommodation (not the
exemption) from the contraceptive coverage requirements. These instructions are intended for use
in connection with whichever accommodation process is in effect at the time an entity submits this
form; either under the July 2015 final rules (80 FR 41318), or the interim final rules published on
October 13, 2017 (82 FR 47792, 82 FR 47838).
An eligible entity may, but is not required to, use a completed copy of this form to provide notice
to its issuer or third party administrator that that the objecting entity has a sincerely held religious
or, if applicable under the accommodation process that is in effect, moral objection to coverage of
all or a subset of contraceptive services, pursuant to 26 CFR 54.9815-2713A, 29 CFR 2590.7152713A, 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.
If the October 13, 2017 interim final rules are in effect, 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
Secretary of Health and Human Services. The guidance is available at
https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Notice-IssuerThird-Party-Employer-Preventive.pdf. Entities should check current regulations and guidance to
determine if revocation is available.
If you intend to utilize the 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, as
applicable, [ ] 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 0938-1344. 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.