INSTRUCTIONSFORMODELNOTICE.PDFVIP

INSTRUCTIONS FOR MODEL NOTICE (OMB Control Number 1210-0150) This model notice may, but is not required to, be used by an eligible organization to provide notice to the Secretary of Health and Human Services (HHS) that the eligible organization has a religious objection to coverage of all or a subset of contraceptive services, pursuant to 26 CFR 54.9815-2713A, 29 CFR 2590.715- 2713A, and 45 CFR 147.131. The notice may also, but is not required to, be used by an organization to provide updated information to HHS. If the eligible organization establishes or maintains more than one plan, it may submit a separate notice for each plan, or it may modify this form accordingly. *Alternatively, an eligible organization may elect to provide notice to HHS without using this model form; or may elect to self-certify using an EBSA Form 700 and send a copy to each health insurance issuer and third party administrator. EBSA Form 700 is accessible at: /ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf. After completing this notice or notice in another form for the same purpose, it should be sent by email to HHS at marketreform@ or by U.S. mail to: Centers for Medicare Medicaid Services Center for Consumer Information Insurance Oversight 200 Independence Avenue, SW Washington, DC 20201 Room 739H Line-by-line instructions: Terminology: As used in this form, the term “PHS Act” refers to the Public Health Service Act (42 USC 300gg et seq.). “ERISA” refers to the Employee Retirement Income Security Act (29 USC 1001 et seq.). The “Code” refers to the Internal Revenue Code (26 USA 1, et seq.). The “Affordable Care Act” refers to the Patient Protection and Affordable Care Act (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152). Introductor