Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)

OMB 0938-1344

Each organization seeking to be treated as an eligible organization that wishes to use the optional accommodation process offered under these final rules must either use the EBSA Form 700 method of self-certification or provide notice to HHS of its religious objection to coverage of all or a subset of contraceptive services.

The latest form for Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653) expires 2021-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction
Form CMS-10653 Self-Certification & Notice to HHS Form and Instruction
CMS-10653 Summary of Changes 1-24-2023.pdf Supplementary Document
CMS-10653 Supporting statement 60d-f.docx Supporting Statement A
CMS-10653 Appendix I - Notice-Issuer-Third-Party-Employer-Preventive.pdf Supplementary Document
CMS-10653 Model Notice to HHS_rev 9-14-22.pdf Supplementary Document
Confirmation of Eligibility for the Individual Contraceptive Arrangement Other-Model Attestation
Notice of Availability of Separate Payments for Contraceptive Services Form and Instruction
Self-Certification & Notice to HHS Form and Instruction

All Historical Document Collections

202302-0938-002 Comment filed on proposed rule and continue	Revision of a currently approved collection	2023-02-02
202111-0938-010 Approved without change	Extension without change of a currently approved collection	2021-11-19
201804-0938-006 Approved with change	Revision of a currently approved collection	2018-04-27
201710-0938-006 Approved without change	Revision of a currently approved collection	2017-10-13
201710-0938-004 Preapproved	New collection (Request for a new OMB Control Number)	2017-10-06

OMB Details

Self-Certification & Notice to HHS

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10653

EBSA FORM 700 - Certification Form

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.