Figure: 28 TAC §21.1110(b)

FIGURE NO. 1

CERTIFICATE OF HEALTH BENEFIT PLAN COVERAGE

* IMPORTANT – This certificate provides evidence of your health coverage. You may need to furnish this certificate if you become eligible under a health benefit plan that excludes coverage for medical conditions you have before you enroll. The definition of preexisting condition is defined by State law. If you become covered under another health benefit plan, check with the plan administrator or health carrier to see if you need to provide this certificate.

1. Date of this certificate: __________________________________

2. Name of issuer of health benefit plan: _______________________

Name of individual: _____________________________________

3. Identification number of individual: _________________________

4. Name of any dependents to whom this certificates applies:

____________________________________________________________

5. Name, address and telephone number of entity responsible for providing this certificate: ________________________________________________

6. For further information, call: _______________________________

_____________________________________________________________

7. (a) For individual coverage:

If all individual(s) identified in items 2 and 4 have at least 18 months of creditable coverage check here ____ and skip items 8 and 9.

(b) For group health benefit plans:

If all individual(s) identified in items 2 and 4 have at least 12 months of creditable coverage check here ____ and skip item 8.

8. Date creditable coverage began: ______________

Date waiting period or affiliation period began: _________

9. For individual insurance: date that a substantially completed application was filed: _________________

10. Date coverage ended: __________ (or check here if coverage is continuing as of the date of this certificate:_____).

Note: Separate certificates will be furnished if information is not identical for each covered individual.

FORM CCC