Get Certification Of Previous Healthcare Coverage. Certification Of Previous Healthcare Coverage

The Certification of Previous Healthcare Coverage is a vital document that verifies an individual's past healthcare coverage. This guide will help you understand the components of the form and provide clear instructions on how to complete it effectively online.

Follow the steps to complete your Certification of Previous Healthcare Coverage.

1. Click the ‘Get Form’ button to access the Certification of Previous Healthcare Coverage form and open it for editing.
2. Begin by entering employee information. Fill in your Social Security Number (SSN), first name, middle initial (MI), and last name in the designated fields.
3. Indicate the last day of your prior coverage by selecting the date from the calendar. Ensure you format it as Month/Day/Year.
4. Next, check all relevant options for coverage ending. This may include you (self), spouse, or dependent child(ren). Provide the names of any dependent child(ren) where applicable.
5. Select the reason for the loss of coverage by checking the appropriate options, such as reaching age 65 or being Medicare eligible, exhaustion of COBRA eligibility, or end of employer coverage. Specify 'Other' if needed.
6. Attest to your continuous coverage by checking the boxes for health, dental, and vision coverage that apply to your situation.
7. Providing an employee signature is essential for certification. Ensure you sign in the designated area.
8. If applicable, the employer or COBRA administrator should fill out the required section to confirm continuous coverage. They need to provide their signature, title, and phone number, along with the last date of coverage for health, dental, or vision.
9. Once all fields are completed, review the form for accuracy. Save your changes, and then you can either download, print, or share the completed Certification of Previous Healthcare Coverage.

Complete your Certification of Previous Healthcare Coverage online today for a seamless experience.