HIPAA - Request for Certificate of Health Coverage

Name of Participant:

Date:

Address:

Telephone Number:

Name and relationship of any dependents for whom certificates are requested (and their address if different from above):

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.]