HIPAA - MODEL FOR CATEGORIES OF BENEFITS (Alternative Method)

Information On Categories of Benefits

1. Date of original certificate:_______________

2. Name of group health plan providing the coverage:_______________

3. Name of participant:_______________

4. Identification number of participant:_______________

5. Name of individual(s) to whom this information applies:_______________

6. The following information applies to the coverage in the certificate that was provided to the individual(s) identified above:

    a. MENTAL HEALTH:_______________

    b. SUBSTANCE ABUSE TREATMENT:_______________

    c. PRESCRIPTION DRUGS:_______________

    d. DENTAL CARE:_______________

    e. VISION CARE:_______________

For each category above, enter "N/A" if the individual had no coverage within the category or either (i) enter both the date that the individual's coverage within the category began and the date that the individual's coverage within the category ended (or indicate if continuing), or (ii) enter "same" on the line if the beginning and ending dates for coverage within the category are the same as the beginning and ending dates for the coverage in the certificate.