Fill and Sign the Information for Alternative Method of Counting Creditable Coverage

Information for Alternative Method of Counting Creditable Coverage Following receipt of the certificate, an entity that uses the alternative method of counting creditable coverage may request that the entity that issued the certificate disclose additional information so that the requesting entity may determine the individual's creditable coverage with respect to a category of benefits. The requested entity may charge the requesting entity the reasonable cost of disclosing the information. 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: a. Mental Health:       b. Substance Abuse Treatment:       c. Prescription Drugs:       d. Dental Care:       e. Vision Care:       For each category enter “N/A” if the individual had no coverage within the category and 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.