S.D. Admin. R. tit. 20, art. 20:06, ch. 20:06:39, app A

Current through Register Vol. 51, page 67, December 16, 2024

Appendix A - [Repealed]

CERTIFICATE OF INDIVIDUAL HEALTH INSURANCE COVERAGE

IMPORTANT - This certificate provides evidence of your health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for medical conditions you have before you enroll, if medical advice, diagnosis, care, or treatment is recommended or received for the condition during the 6 months before you enroll 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 establish your right to buy coverage for yourself or your family.

1. Date of this certificate: _______________.

2. Name of policyholder: ________________________________________________.

3. Identification number of policyholder: ___________________________________.

4. Name of any dependents to whom this certificate applies: ________________

_____________________________________.

5. Name, address, and telephone number of issuer responsible for providing this certificate: ________________________________________________________

___________________________________________________________________

___________________________________________________________________

6. For further information, call: __________________________________________.

7. If all individual(s) identified in items 2 and 4 have at least 18 months of creditable coverage (disregarding periods of coverage before a 63-day break), check here ___ and skip items 8 and 9.

8. Date coverage began: _______________.

9. Date that a substantially completed application was received from the policyholder: ______

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 the policyholder and each dependent.

S.D. Admin. R. tit. 20, art. 20:06, ch. 20:06:39, app A

42 SDR 83, effective 12/3/2015