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COMAR 10.09.24.11

1108 State of Maryland Medical Assistance Manual Revised July 2012 Attachment C- Certificate of Group Health Plan Coverage

DEPARTMENT OF HEALTH AND MENTAL HYGIENE 201 WEST PRESTON STREET BALTIMORE, MARYLAND 21201

CERTIFICATE OF GROUP HEALTH PLAN COVERAGE

NAME OF ENROLLEE = ANGELA J D------- NAME IF GROUP HEALTH PLAN= MARYLAND MEDICAL ASSISTANCE MEDICAL ASSISTANCE N = 02----------------10

Periods of coverage during the past 24 months: FROM: 06/01/1995

THROUGH 12/13/1997

Federal law, under the „Health Insurance-Portability and Accountability Act 1996‟, requires that we provide you with this CERTIFICATE OF GROUP HEALTH PLAN COVERAGE. This certificate provides evidence of your health coverage under the Maryland Medical Assistance Program. You may need to furnish this certificate if you become eligible under a health plan other than Medical Assistance 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 a health plan other Medical Assistance, check with the plan administrator to see if you need to provide this certificate. You may also need this certificate to buy an insurance policy that includes coverage for medical conditions that are present before you enroll.

If you have any questions about this certificate, please call (410)767-5800 in the Baltimore area or (800) 492-5231 outside the Baltimore area.

Certificate issued by: Recipient Services Section Medical Care Operations Administration 201 W. Preston Street Baltimore, Maryland 21201