OMB control number
Coverage of Certain Preventive Services Under the Affordable Care Act (CMS-10653)
OMB 0938-1344 · HHS/CMS.
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 2029-07-31 and is listed under ICR 202602-0938-008.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-10653 Notice of Availability of Separate Payments for Contraceptive Services | Form and Instruction |
| Form CMS-10653 EBSA FORM 700 - Certification Form | Form and Instruction |
| CMS-10653 Supporting Statementf.pdf (document unavailable) | Supporting Statement A |
| CMS-10653 Model Notice to HHS.pdf | Supplementary Document |
| CMS-10653 Appendix I - Notice-Issuer.pdf | Supplementary Document |
 Notice of Availability of Separate Payments for Contraceptive Services |
Form and Instruction |
| Notice of Availability of Separate Payments for Contraceptive Services |
Form and Instruction |
| Self-Certification & Notice to HHS |
Form and Instruction |
| Self-Certification & Notice to HHS |
Form and Instruction |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 202602-0938-008 | Reinstatement without change of a previously approved collection | 2026-02-09 | ||
| 202302-0938-002 | Revision of a currently approved collection | 2023-02-02 | Comment filed on proposed rule and continue | |
| 202111-0938-010 | Extension without change of a currently approved collection | 2021-11-19 | Approved without change | |
| 201804-0938-006 | Revision of a currently approved collection | 2018-04-27 | Approved with change | |
| 201710-0938-006 | Revision of a currently approved collection | 2017-10-13 | Approved without change | |
| 201710-0938-004 | New collection (Request for a new OMB Control Number) | 2017-10-06 | Preapproved |
OMB Details
Self-Certification & Notice to HHS
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| 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.