Health Insurance Portability (HIPAA) - Sample Notices and Certificates

Friday, August 22, 2008
These sample forms are provided as a general guideline for your review only and with the understanding that neither the publisher nor the writers are providing legal advice or other professional service. The law changes regularly and varies from state to state, and you should not rely on or use these or any form without consultation with a competent attorney in your state.



Information On Categories of Benefits

1. Date of original certificate:_______________
2. Name of group health plan providing the coverage:_______________
3. Name of participant:_______________
4. Identification number of participant:_______________
5. Name of individual(s) to whom this information applies:_______________
6. The following information applies to the coverage in the certificate that was provided to the individual(s) identified above:
a. MENTAL HEALTH:_______________
c. PRESCRIPTION DRUGS:_______________
d. DENTAL CARE:_______________
e. VISION CARE:_______________

For each category above, enter "N/A" if the individual had no coverage within the category or either (i) enter both the date that the individual's coverage within the category began and the date that the individual's coverage within the category ended (or indicate if continuing), or (ii) enter "same" on the line if the beginning and ending dates for coverage within the category are the same as the beginning and ending dates for the coverage in the certificate.


Important Notice of Your Right to
Documentation of Health Coverage

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 Heath 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 exclusion 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 condition 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 attached form and return it to:

[Insert Name of Entity]:
[Insert Address]:
For additional information contact: [Insert Telephone Number]

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.

Request for Certificate of Health Coverage

Name of Participant:




Telephone Number:

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

  1. Date of this certificate: ______________

  2. Name of group health plan: ______________________________

  3. Name of participant: ______________________________

  4. Identification number of participant: ______________

  5. Name of individuals 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 5 has (have) 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 (or if coverage has not ended, enter "continuing"): ______________

[Note: separate certificates will be furnished if information is not identical for the participant and each beneficiary.]

Statement of HIPAA Portability Rights

IMPORTANT - KEEP THIS CERTIFICATE. This certificate is evidence of your coverage under this plan. Under a federal law known as HIPAA, you may need evidence of your coverage to reduce a preexisting condition exclusion period under another plan, to help you get special enrollment in another plan, or to get certain types of individual health coverage even if you have health problems.

Preexisting condition exclusions. Some group health plans restrict coverage for medical conditions present before an individual's enrollment. These restrictions are known as "preexisting condition exclusions." A preexisting condition exclusion can apply only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 months before your "enrollment date." Your enrollment date is your first day of coverage under the plan, or, if there is a waiting period, the first day of your waiting period (typically, your first day of work). In addition, a preexisting condition exclusion cannot last for more than 12 months after your enrollment date (18 months if you are a late enrollee). Finally, a preexisting condition exclusion cannot apply to pregnancy and cannot apply to a child who is enrolled in health coverage within 30 days after birth, adoption, or placement for adoption.

If a plan imposes a preexisting condition exclusion, the length of the exclusion must be reduced by the amount of your prior creditable coverage. Most health coverage is creditable coverage, including group health plan coverage, COBRA continuation coverage, coverage under an individual health policy, Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), and coverage through high-risk pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates like this one. If you do not receive a certificate for past coverage, talk to your new plan administrator.

You can add up any creditable coverage you have, including the coverage shown on this certificate. However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a plan may not have to count the coverage you had before the break.

  • Therefore, once your coverage ends, you should try to obtain alternative coverage as soon as possible to avoid a 63-day break. You may use this certificate as evidence of your creditable coverage to reduce the length of any preexisting condition exclusion if you enroll in another plan.

Right to get special enrollment in another plan. Under HIPAA, if you lose your group health plan coverage, you may be able to get into another group health plan for which you are eligible (such as a spouse's plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days. (Additional special enrollment rights are triggered by marriage, birth, adoption, and placement for adoption.)
  • Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a spouse's plan), you should request special enrollment as soon as possible.

Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on anything related to your health. Also, a group health plan may not charge you (or your dependents) more for coverage, based on health, than the amount charged a similarly situated individual.

Right to individual health coverage. Under HIPAA, if you are an "eligible individual," you have a right to buy certain individual health policies (or in some states, to buy coverage through a high-risk pool) without a preexisting condition exclusion. To be an eligible individual, you must meet the following requirements:
  • You have had coverage for at least 18 months without a break in coverage of 63 days or more;
  • Your most recent coverage was under a group health plan (which can be shown by this certificate);
  • Your group coverage was not terminated because of fraud or nonpayment of premiums;
  • You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or continuation coverage under a similar state provision); and
  • You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other health insurance coverage.

The right to buy individual coverage is the same whether you are laid off, fired, or quit your job.
  • Therefore, if you are interested in obtaining individual coverage and you meet the other criteria to be an eligible individual, you should apply for this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break.

State flexibility. This certificate describes minimum HIPAA protections under federal law. States may require insurers and HMOs to provide additional protections to individuals in that state. For more information. If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) toll-free at 1-866-444-3272 (for free HIPAA publications ask for publications concerning changes in health care laws). You may also contact the CMS publication hotline at 1-800-633-4227 (ask for "Protecting Your Health Insurance Coverage"). These publications and other useful information are also available on the Internet at:, the DOL's interactive web pages - Health Elaws, or


If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption.

SAMPLE NOTICE TO COBRA BENEFICIARIES (To be sent by November 1, 1996)

The Health Insurance Portability and Accountability Act of 1996 made important changes in COBRA continuation coverage rules that will take effect on January 1, 1997. A comparison of the current rules and the rules that will become effective on January 1, 1997, is provided below. Please review these changes carefully Û they may have an effect on your continuation coverage.

Extension of Coverage for Disabled Beneficiaries
A qualified beneficiary may be eligible for an extension of up to 11 months of COBRA continuation coverage due to disability, if the Plan Administrator receives notification of the Social Security Administration's determination of disability, in writing, within 60 days of the date the determination is made and within the initial 18 months of COBRA continuation coverage.

Currently, only COBRA beneficiaries determined by the Social Security Administration to have been totally disabled on the date of the qualifying event (i.e., the employee's termination of employment, or reduction in hours) making that individual eligible to elect COBRA coverage were eligible to extend continuation coverage for an additional 11 months, to a maximum of 29 months of COBRA continuation coverage.

Effective on January 1, 1997, an extension of up to 11 months of continuation coverage will be available to a qualified beneficiary who is totally disabled during the first 60 days after COBRA continuation coverage begins. Note: the new rule applies to those whose COBRA coverage began in 1996 who are still covered on January 1, 1997, as well as those who become eligible for COBRA in 1997.

Coverage for Newborns & Children Placed for Adoption
Newborn infants and children placed for adoption can be enrolled for COBRA continuation coverage in accordance with the terms of the [name of plan] group health plan. A child is considered to be placed for adoption when the adoptive parent assumes and retains the legal obligation for the support of the child, in accordance with an order to that effect issued by a proper court or other agency which has the authority to issue such order.

Under the current rules, a newborn infant or a child placed for adoption could be enrolled for COBRA continuation coverage; however, the infant or adopted child would not have independent rights as a COBRA beneficiary.

Effective on January 1, 1997, a newborn infant or child placed for adoption with the covered employee will be entitled to receive COBRA continuation coverage as a qualified beneficiary. To enroll a newborn or a child placed with you for adoption, you must notify the Plan Administrator within (plan's time limit for enrolling newly eligible dependent, e.g. 30 days) of your newborn's date or birth or (repeat the plan's time limit) of the date a child is placed with you for adoption. Note: if you added a dependent child during your first 18 months of COBRA continuation coverage and you are covered under COBRA on January 1, 1997, that child will become a qualified beneficiary on January 1, 1997.
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