Continuation of Coverage After Group Insurance Termination

Note: Fields marked with an * indicates required field

Instructions: The former insured or legal representative should complete and submit this form within 10 days of group termination with McLaren Health Plan Community (MHP Community). At the bottom of the form you will be able to attach the required documentation for your request before you select submit.

Contact Information

Last Name: *

First Name: *

Middle Initial:

MHP Community Plan ID Number: *

Address: *

City: *

State: *

Zip Code: *

Date of Birth: *

Home Phone Numer:

Employer Name (Where MHP Community Insurance was Purchased): *

Request for Coverage

Attestation of No Coverage: *

Reason requesting continued coverage: *

    If you selected above that your treating provider does not participate with your new insurance provider, what is the name of your new insurance provider:

    If you indicated above that you do not have health insurance, what is the reason:

    If you indicated above that you are currently pregnant, please select your current trimester.

What is the name of the condition(s) you have for which you need continued coverage? *

When did this condition start? *

Last treatment date for this condition: *

Treatment or service(s) needing continued coverage: *

    If you indicated continued coverage is needed for diagnostic testing, provide the testing needed:

    If you indicated continued coverage is needed for a surgical procedure, provide the surgical procedure needed:

    If you indicated above that other treatment or services not listed were needed, please list them:

List all provider(s) you want covered under this request: *

Upload Required Documentation:

  • Attach documentation verifying provider is not part of network with current health plan
  • Attach clinical documentation from specialist to support need for ongoing care
  • Attach a copy of the new plan Summary of Benefit Coverage (SBC)

NOTE: File names for attachments must NOT contain special characters or spaces (dashes are allowed). Ex. file-smith.pdf

Please fax medical necessity documentation exceeding a total of 9 MB in size to 833-540-8648.

    Attach clinical documentation from specialist to support need for ongoing care:

    Attach documentation verifying provider is not part of network with current plan:

    Attach a copy of the new plan Summary of Benefit Coverage:

Typing your name here indicates that all of the above information is accurate and acts as your electronic signature. *

Today's Date *