PSMI Health Plans
PO Box 19002
Provo, UT 84605-9002
Toll Free: 800-286-4160 Fax: 801-375-2770








The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires a group health plan to provide a "certificate of creditable coverage" to individuals whose coverage under the plan is ending, or to anyone who requests such a certificate. The purpose of this "creditable coverage" is to give such an individual credit toward the satisfaction of waiting periods a new insurance plan may have for pre-existing conditions. Below is your certificate of creditable coverage.



Certificate of Creditable Coverage

Date of Issuance:

Name of Group Health Plan:

Name of Employee Participant:

Employee SSN:

Date Creditable Coverage Began:

Date Creditable Coverage Ended:
 01/14/2004

 PROFESSIONAL STAFF MANAGEMENT, INC

 POST, MARK

 111111111

 1/1/2002

 Continuing as of the date of this certificate
Covered Dependents
Name SSN Rel Sex DOB Beg Date End Date
SUSAN POST
DEFAS A. POST
122222222
133333333
 SPO
SON
 F
M
 04/16/1970
12/31/2001
 1/1/2002
1/1/2002