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

OMB 0938-1344

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.

OMB Details

Self-Certification & Notice to HHS

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10653EBSA FORM 700 - Certification FormFillable FileableForm and instruction

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


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