CMS-10653 Model Attestation for Confirmation of Eligibility 10-4-22

OMB Control No. 0938-1344

Expiration Date: XX/XX/XXXX

Model Attestation - Confirmation of Eligibility for the Individual Contraceptive Arrangement

Instructions: The following language may, but is not required to, be used by a participant, beneficiary, or enrollee (or an authorized representative of a participant, beneficiary, or enrollee) to confirm to a provider of contraceptive services that their plan or coverage is sponsored, provided, or arranged by an objecting entity and does not provide coverage for all or a subset of contraceptive services:

“I certify that I am enrolled (or am an authorized representative of a person who is enrolled) in an employer-sponsored health plan or individual health insurance coverage that does not provide coverage for all or a subset of contraceptive services as generally required under the Affordable Care Act.”

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 0938-1344. The time required to complete this information collection is estimated to average 5 minutes per respondent, 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: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.