Certificate of Group Health Plan Coverage
IMPORTANT – This certificate provides evidence of your prior health coverage. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll. This certificate may need to be provided if medical advice, diagnosis, care or treatment was recommended or received for the condition within the 6-month period prior to your enrollment 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 buy, for yourself or your family, an insurance policy that does not exclude coverage for medical conditions that are present before you enroll.
Name of group health plan:
AVANT MINISTRIES MISSIONARY MEDICAL AID PLAN
A description of the section goes here.
Name of participant
Name(s) of any dependent to whom this certificate applies.
To receive confirmaiton of this form.
Name, address, and telephone number of plan administrator or issuer responsible for providing this certificate:
10,000 North Oak Trafficway
Kansas City, MO 64155
For further information call: 816-734-8500
Date coverage ended
Do Not Fill This Out