Form EBSA700 Preventive Health Services Certification

PREVENTIVE HEALTH SERVICES CERTIFICATION

This form is to be used to certify that the group health plan established or maintained by the organization listed below is eligible for the accommodation, as defined in 2590.715-2718A(a). Please fill out this form completely.
Name of the organization sponsoring the plan
Name and title of the individual who is authorized to make, and makes, this certification on behalf of the organization
Mailing and email addresses and phone number for the individual listed above
Contraceptive services for which the organization will not establish, maintain, administer or fund coverage
I certify that the organization opposes providing coverage for some or all of any contraceptive services that otherwise would be required to be covered on account of religious objections; the organization is organized and operates as a nonprofit entity; and the organization holds itself out as a religious organization. I declare that I have made this certification, and that, to the best of my knowledge and belief, it is true and correct. I also declare that this certification is complete. ______________________________________ Signature of the individual listed above ______________________________________ Date
Failure to provide the requisite notice to group health insurance issuer or third party administrator renders a group health plan ineligible for the accommodation.

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 1210-XXXX . The time required to complete this information collection is estimated to average 50 minutes per response, 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: G. Christopher Cosby, Office of Policy and Research, Department of Labor, Employee Benefits Security Administration, 200 Constitution Avenue NW., Room N–5718, Washington, DC 20210

EBSA 700

February 2013