Health Plan Certificate Template - Free Download
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Health Plan Certificate Template
Health Plan Certificate Template
CERTIFICATE OF GROUP HEALTH PLAN COVERAGE
1. Date of this certificate: ______________
2. Name of group health plan: _______________
_____________________________________
3. Name of participant: ____________________
4. Identification number of participant: _______
5 Name of individuals to whom this certificate
applies: _____________________________
____________________________________
6. Name, address, and telephone number of plan
administrator or issuer responsible for providing
this certificate: _______________________
___________________________________
7. For further information, call: _____________
8. If the individual(s) identified in line 5 has (have)
at least 18 months of creditable coverage
(disregarding periods of coverage before
a 63-day break), check here and skip lines 9 and
10: ___
9. Date waiting period or affiliation period
(if any) began:
_____________________________
10. Date coverage began: _________________
11. Date coverage ended (or if coverage has not
ended, enter “continuing”): ____________
[Note: separate certificates will be furnished if information is not identical for the participant and each beneficiary.]
Statement of HIPAA Portability Rights
IMPORTANT KEEP THIS CERTIFICATE. This certificate is evidence of your coverage under
this plan. Under a federal law known as HIPAA, you may need evidence of your coverage to reduce a
preexisting condition exclusion period under another plan, to help you get special enrollment in another
plan, or to get certain types of individual health coverage even if you have health problems.
Preexisting condition exclusions. Some group health plans restrict coverage for medical conditions
present before an individual’s enrollment. These restrictions are known as “preexisting condition
exclusions.” A preexisting condition exclusion can apply only to conditions for which medical advice,
diagnosis, care, or treatment was recommended or received within the 6 months before your “enrollment
date.” Your enrollment date is your first day of coverage under the plan, or, if there is a waiting period,
the first day of your waiting period (typically, your first day of work). In addition, a preexisting condition
exclusion cannot last for more than 12 months after your enrollment date (18 months if you are a late
enrollee). Finally, a preexisting condition exclusion cannot apply to pregnancy and cannot apply to a
child who is enrolled in health coverage within 30 days after birth, adoption, or placement for adoption.
If a plan imposes a preexisting condition exclusion, the length of the exclusion must be reduced by the
amount of your prior creditable coverage. Most health coverage is creditable coverage, including group
health plan coverage, COBRA continuation coverage, coverage under an individual health policy,
Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), and coverage through high-risk
pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates like
this one. If you do not receive a certificate for past coverage, talk to your new plan administrator.
You can add up any creditable coverage you have, including the coverage shown on this certificate.
However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a
plan may not have to count the coverage you had before the break.
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source: dol.gov
Health Plan Certificate Template
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