CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22

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

Model Attestation - Confirmation of Eligibility for the Individual Contraceptive Arrangement
Instructions: The following language may, but is not required to, be used by a participant,
beneficiary, or enrollee (or an authorized representative of a participant, beneficiary, or enrollee)
to confirm to a provider of contraceptive services that their plan or coverage is sponsored,
provided, or arranged by an objecting entity and does not provide coverage for all or a subset of
contraceptive services:
“I certify that I am enrolled (or am an authorized representative of a person who is enrolled) in
an employer-sponsored health plan or individual health insurance coverage that does not provide
coverage for all or a subset of contraceptive services as generally required under the Affordable
Care Act.”

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

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 5 minutes per respondent, 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.