Get Sample Certificate of Creditable Coverage

Sample Certificate of Creditable Coverage Certificate of Group Health Plan Coverage This certificate provides evidence of your prior health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll* If you become covered under another group health plan check with the plan administrator to see if you need to provide this certificate. You may also need not exclude coverage for medical conditions that are present before you enroll* 1. Date of this certificate 2. Name of group health plan 3. Name of participant 4. Identification number of participant 5. Name of any dependents 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 3 and line 5 has 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 the date of this certificate. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll* If you become covered under another group health plan check with the plan administrator to see if you need to provide this certificate. You may also need not exclude coverage for medical conditions that are present before you enroll* 1. You may also need not exclude coverage for medical conditions that are present before you enroll* 1. Date of this certificate 2. Name of group health plan 3. Name of participant 4. Identification number of participant 5. Date of this certificate 2. Name of group health plan 3. Name of participant 4. Identification number of participant 5. Name of any dependents to whom this certificate applies 6. Name address and telephone number of plan administrator or issuer responsible for providing this certificate 7. Name of any dependents 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 3 and line 5 has at least 18 months of creditable coverage disregarding periods of coverage before a 63-day break check here and skip lines 9 and 10. For further information call 8. If the individual s identified in line 3 and line 5 has 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 the date of this certificate. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll* If you become covered under another group health plan check with the plan administrator to see if you need to provide this certificate. You may also need not exclude coverage for medical conditions that are present before you enroll* 1. Date of this certificate 2. Name of group health plan 3. Name of participant 4. Identification number of participant 5. .