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EBSA Form 700 Eligible Organization Self-Certification
Coverage of Certain Preventive Services under the Affordable Care Act—Private Sector
CMS-10653 Certification_rev 2-2-23
OMB: 1210-0150
OMB.report
DOL/EBSA
OMB 1210-0150
ICR 202207-1210-003
IC 205659
EBSA Form 700 Eligible Organization Self-Certification
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1210-0150 can be found here:
2024-10-08 - Extension without change of a currently approved collection
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