Recent changes in Federal law may affect your health coverage if you are enrolled or become eligible to enroll in health coverage that excludes coverage for preexisting medical conditions.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage may be excluded for medical conditions present before you enroll.  Under the law, a preexisting condition exclusive generally may not be imposed for more than 12 months (18 months for a late enrollee).  The 12-month (or 18-month) exclusion period is reduced by your prior health coverage.  You are entitled to a certificate that will show evidence of your prior health coverage.  If you buy health insurance other than through an employer group health plan, a certificate of prior coverage may help you obtain coverage without a preexisting exclusion. Contact your State Insurance Department for further information.

For employer group health plans, these changes generally take effect at the beginning of the first plan year starting after June 30, 1997.  For example, if your employer’s plan year begins on January 1, 1998, the plan is not required to give you credit for your prior coverage until January 1, 1998.

You have the right to receive a certificate of prior health coverage since July 1, 1996. You may need to provide other documentation for earlier periods of health care coverage.  Check with your new plan administrator to see if your new plan excludes coverage for preexisting conditions and if you need to provide a certificate or other documentation of your previous coverage.

To get a certificate, complete the form and return it to:

Crawford County

Human Resources

PO Box 249

Girard, KS 66743

The certificate must be provided to you promptly.  Keep a copy of this completed form.  You may also request certificates for any of your dependents (including your spouse) who were enrolled under your health coverage.

Name of Participant: ______________________________ Date: _____________

SSN: _______________________________ DOB: ________________________

Address:_______________________________________________________________

Telephone Number: ___________________ Signature: _____________________

Name and Relationship of any dependents for whom certificates are requested (and their addresses if different from above):

Name: __________________________Relationship:_______________________

Address (if different):

__________________________________________________________

Name: __________________________Relationship:_______________________

Address (if different):

__________________________________________________________

Name: __________________________Relationship:_______________________

Address (if different):

__________________________________________________________

Name: __________________________Relationship:_______________________

Address (if different):

__________________________________________________________

Name: __________________________Relationship:_______________________

Address (if different):

__________________________________________________________

Name: __________________________Relationship:_______________________

Address (if different):

__________________________________________________________