Health Insurance Portability
and Accountability Act of 1996

Certificate of Prior Coverage

At the time of your enrollment in Graphic Arts Benefit Corporation's Medical Plan the provisions of Federal Legislation known as HIPAA were in effect.  This legislation allows an individual to receive transfer credit for prior coverage in considering any Pre-existing Condition Limitations which may be contained in the GABC Medical Plan.

The pre-existing exclusion of benefits for new enrollment is twelve (12) months from the date of coverage.  It excludes coverage for ``Pre-existing Conditions" for an illness or injury for which medical treatment services were rendered during the six-month period immediately preceding the effective date of coverage under the Graphic Arts Benefit Corporation.

The pre-existing exclusion period may be reduced by the number of months of prior health coverage.

In order to receive credit for prior periods of uninterrupted coverage you must submit a valid ``Certificate of Prior Coverage".  An employer's requirement for service is not considered when applying the provisions of HIPAA for transfer credit.

If you have not had previous coverage in the twelve (12) month period prior to enrollment with Graphic Arts Benefit Corporation please complete, sign this card and return to GABC.

Enter your information in the space below and submit this form to GABC so we can begin processing the change.  You will need to print a hard copy, sign/date it and mail or fax it to us for verification.  It'll help us to serve you better.

I have no prior creditable coverage.

Employee Name:

Employer:

Social Security No:

Signed:

Dated:

Please Click on the SUBMIT BUTTON only ONCE. Your request will be processed.

Don’t forget to print this form sign & date it and mail to:

Graphic Arts Benefit Corporation
6411 Ivy Lane, Suite 700
Greenbelt, MD 20770-1411