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:
11. Date coverage ended:
12. (Or today’s date if coverage continues as of the date of this certificate:)
Note: Separate certificates will be furnished if information is not identical for the participant and each dependent.
SOURCE: Alexander Hamilton Institute, "Guide to HIPAA," 1997.
Workforce Extra, November 1998, p. 1.