Fill and Sign the Sample Form 12 Written Certification of Past Coverage

Basic form  James R. McDade (ver 02-21-01) 209-667-2300 WRIT TE N C ER TIF IC ATIO N O F G RO UP H EA LTH P LA N C O VER AG E Em plo yers u se t h is f o rm t o p ro vid e p ro of o f h ealt h c o vera g e a s r e q uir e d b y H IP PA . (D ele te this n ote p rio r t o u se .)D ate : _ _________________________T O : ________________________________________[N am e o f E m plo ye e; S pouse ; o r A dult D ependent][ A ddre ss][C it y , S ta te , Z ip ]Dear [Name of Employee; Spouse; or Adult Dependent] and any dependent minor who was enrolled in the [Group Health Plan Name] (hereinafter called "Group Health Plan") of [EMPLOYER NAME]:This certification documents your coverage under the above-referenced Group Health Plan. 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. This certificate may need to be provided if medical advice, diagnosis, care or treatment was recommended or received for the condition before your enrollment in the new plan. 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 this certificate to buy, for yourself or your family, an insurance policy that does not exclude coverage for medical conditions that are present before you enroll. If you have any questions, please call or write the certificate issuer identified below.PAR TIC IP AN T'S P LA N I D EN TIF IC ATIO N N UM BER : _ ______________________ C overa g e P erio ds D ocu m en te d B y T his C ertif ic ate E M PLO YEE B EN EFIT CO VER AG E P ER IO DCO BR A C O VER AG E PER IO D, if a pp lic a bleB EN EFIC IA RY N AM ESTA R T D ATEE N D D ATES TA R T D ATEE N D D ATEW ait in g p erio d , if a ny, p rio r t o c o ve ra ge e lig ib ilit y : _ __________________________________IS S U ER O F T H IS C ER TIF IC ATE :N am e: _____________________________________________A dd re ss: _____________________________________________P ho ne: ____________________B Y: _ _ _______ ____________________ Date : _ _ _____________________