Model Notices

CAA

• No Surprises Act Model Notice

COBRA

• Initial COBRA Notice
• Initial COBRA Notice (Spanish)
• COBRA Election Notice
• COBRA Election Notice (Spanish)

ERISA

• ERISA Rights Statement
• ERISA Summary Annual Report

FMLA

• FMLA General Notice (in English)
• FMLA General Notice (in Spanish)
• Eligibility & Rights and Responsibilities Notice
• Designation Notice
• Certification of Health Care Provider for Employee’s Serious Health Condition (PDF)
• Certification of Health Care Provider for Family Member’s Serious Health Condition (PDF)
• Certification of Qualifying Exigency For Military Family Leave (PDF)
• Certification for Serious Injury or Illness of Covered Servicemember -- for Military Family Leave (PDF)
• Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave (PDF)

ACA

• Grandfathered Plan Model Notice
• Grandfathered Plan Model Notice (Spanish)
• Exchange Notice: Employers With a Group Health Plan
• Exchange Notice: Employers With a Group Health Plan (Spanish)
• Exchange Notice: Employers Without a Group Health Plan
• Exchange Notice: Employers Without a Group Health Plan (Spanish)
• Lifetime Limits Model Notice
• Lifetime Limits Model Notice (Spanish)
• Notice of Adverse Benefit Determination
• Notice of Final Internal Adverse Benefit Determination
• Notice of Final External Adverse Benefit Determination
• Notice of Final External Adverse Benefit Determination (Spanish)
• Notice of Nondiscrimination Under 1557
• Patient Protections Model Notice
• Patient Protections Model Notice (Spanish)
• Summary of Benefits and Coverage (SBC)
• Uniform Glossary of Coverage and Medical Terms

HIPAA

• Employer CHIP Notice
• Employer CHIP Notice (Spanish)
• Notice of Privacy Practices Booklet (in English)
• Notice of Privacy Practices Full Page (in English)
• Notice of Privacy Practices Layered (in English)
• Notice of Privacy Practices Text-only (in English)
• Notice of Privacy Practices Booklet (in Spanish)
• Notice of Privacy Practices Full Page (in Spanish)
• Notice of Privacy Practices Layered (in Spanish)
• Notice of Privacy Practices Text-only (in Spanish)
• Notice of Special Enrollment Rights

Medicare

• Part D Creditable Coverage Notice to Eligible Individuals
• Part D Non-Creditable Coverage Notice to Eligible Individuals
• Model Creditable Coverage Disclosure Notice (in Spanish)
• Model Non-Creditable Coverage Disclosure Notice (in Spanish)

HSA

• Notice to Employees Regarding Employer Contributions to HSA

Newborns and Mothers Health Protection Act

• Newborns' and Mothers' Health Protection Act Model Language

USERRA

• USERRA: Notice of Your Rights Under USERRA

Wellness Programs

• EEOC Wellness Notice
• Notice of Availability of Reasonable Alternative Standard

WHCRA

• WHCRA: Women's Health and Cancer Rights Act Notice