Self-Certification or Notification

Coverage of Certain Preventive Services under the Affordable Care Act—Private Sector

OMB: 1210-0150

IC ID: 205659

Documents and Forms

Document Name Document Type
CMS-10653 Model Notice to HHS_clean.docx Other-Model Notice
EBSA Form 700 Eligible Organization Self-Certification CMS-10653 Certification_clean.docx www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf Form