Get Certificate Of Creditable Coverage

The Certificate Of Creditable Coverage is an essential document that provides evidence of prior health insurance coverage. This guide offers clear, step-by-step instructions to help you fill out the form online effectively.

Follow the steps to complete the Certificate Of Creditable Coverage online.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Enter the date of the certificate by clicking on the designated field and typing in the current date.
3. Provide the name of the employer or group health plan, which in this case is the Hospitalization and Medical Expense Program.
4. Next, input the name of the participant by clicking on the appropriate field and typing the participant's full name.
5. Fill in the participant's identification number in the designated box to ensure accurate identification.
6. List any dependents that the certificate applies to or indicate if it covers a family by entering their names as needed.
7. Provide the name, address, and phone number of the employer plan administrator or issuer responsible for issuing the certificate.
8. If applicable, check the box indicating that the individual has at least 18 months of creditable coverage, and skip to step 10.
9. If you are not skipping, enter the start date of any waiting period or affiliation period, if applicable.
10. Record the date when the coverage began by typing it into the corresponding field.
11. Finally, enter the date when the coverage ended, or check if the coverage is ongoing as of the certificate date.

Complete the Certificate Of Creditable Coverage online for a streamlined experience.