Rule 20:06:40:0A Example of Certificate of Prior Group Health Plan Coverage.
DEPARTMENT OF REVENUE AND REGULATION
OF LABOR AND REGULATION
OF CERTIFICATE OF PRIOR GROUP HEALTH PLAN COVERAGE
Source: 24 SDR 35, effective September 29, 1997.
CERTIFICATE OF PRIOR 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. This certificate may need to be provided if medical advice,
diagnosis, care, or treatment was recommended or received for the condition
within the 6 month period prior to 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.
of this certificate: _______________.
of group health plan: _____________________________________________.
of participant: ___________________________________________________.
number of participant: _____________________________________.
of any dependents to whom this certificate applies: _________________ ________________________________________________________________________
address, and telephone number of plan administrator or issuer responsible for
providing this certificate: ________________________________
further information, call: ____________________________________________.
the individual(s) identified in line 3 and 5 has at least 18 months of credible
coverage (disregarding periods of coverage before a 63-day break), check here
___ and skip lines 9 and 10.
waiting period of affiliation period (if any) began: _____________.
coverage began: _______________.
coverage ended: _______________ (or check if coverage is continuing as of the
date of this certificate ___).
certificates will be furnished if information is not identical for the
participant and each beneficiary.
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