EBSA Form 700
Entity Mandating Form: Department of Labor's Employee Benefits Security Administration (EBSA).
Applicability: The Affordable Care Act (ACA) requires group health plans to cover certain preventive care services, including contraceptives, without cost sharing. An employer with religious objections to covering contraceptives may be eligible for an accommodation. The employer may certify to its health insurance issuer (for insured health plans) or a third-party administrator (for self-insured plans) that it qualifies for the accommodation. (Alternatively, the employer may notify the Department of Health and Human Services of its objections.)
Obtaining This Form: An employer may download this form directly from the EBSA website.