CMS-10653 EBSA FORM 700 - Certification Form

OMB Control No. 0938-1344
Expiration Date: XX/XX/XXXX

EBSA FORM 700-- CERTIFICATION
(revised January 2023)
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 and Services
Administration (HRSA). The HRSA-Supported Guidelines provide exemptions for, among other
entities and individuals, group health plans and student health insurance coverage under certain
circumstances related to an objection to providing contraception coverage. An optional
accommodation process is available for eligible entities, under which the entity’s issuer or third
party administrator instead provides or arranges separate payments for contraceptive services. The
accommodation process for eligible organizations is described in 26 CFR 54.9815-2713A, 29 CFR
2590.715-2713A, and 45 CFR 147.131. These instructions and model notice may be used to claim
an accommodation (not the exemption) from the contraceptive coverage requirements for an
eligible organization. These instructions are intended for use in connection with whichever
accommodation process for eligible organizations is in effect at the time an entity submits this
form. Entities should check current regulations and guidance to determine which accommodation
process(es) are in effect.
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 the objecting entity has a sincerely held religious
objection, consistent with applicable rules, to coverage of all or a subset of contraceptive services,
pursuant to 26 CFR 54.9815-2713A, 29 CFR 2590.715-2713A, and 45 CFR 147.131.
Alternatively, an objecting entity may provide notice to the Secretary of Health and Human
Services. A model notice is available at - http://www.cms.gov/cciio/resources/Regulations-andGuidance/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 26 CFR 54.9815-2713A, 29 CFR 2590.715-2713A, and 45 CFR 147.131. Entities
should check current regulations and guidance to determine if revocation is available.
If an eligible organization intends to utilize the accommodation process and chooses to use this
form instead of notifying the Secretary of Health and Human Services, the eligible organization
should fill out this form completely and provide it to the eligible organization’s 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 objection to
providing coverage for all or a subset of 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.