Teamsters Joint Council No. 83 of Virginia

Procedure to Request a Certificate of Coverage

The Fund is required to provide a Certificate of Creditable Coverage (HIPAA Certificate) to each individual who submits a request, provided that the request is made while the individual is covered under the Plan or within 24 months of the termination of coverage under the Plan. The request can be made by someone else on behalf of the individual. For example, an individual who previously was covered under this Plan may authorize a new plan in which the individual enrolls to request a certificate of the individual's creditable coverage from the Plan.

Requests for certificates should be addressed to: Teamsters Joint Council No. 83 of Virginia Health & Welfare Fund 8814 Fargo Road, Suite 200, Richmond, VA 23229.

Requests made by phone are accepted only if the certificate is to be mailed to the address that the Fund Office has on file for the individual for whom the request pertains. Otherwise the request must be made in writing.

Requirements for Requests

All requests must include the following information:

• The name of the individual for whom the certificate is requested;
• The last date that the individual was covered under the Plan;
• The name of the participant that enrolled the individual in the Plan;
• A telephone number to reach the individual for whom the certificate is requested, in the event of any difficulties.

Requirements for Written Requests:

All written requests must include the following information:

• The name of the person making the request and evident of that person's authority to request and receive the certificate on behalf of the individual;
• The address to which the certificate should be mailed;
• The requestor's signature.

After receiving a request that meets these requirements, the Fund will act in a reasonable and prompt fashion to provide the certificate.