Notice Form For Your Rights About Heath Insurance Coverage
Download a blank fillable Notice Form For Your Rights About Heath Insurance Coverage in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Notice Form For Your Rights About Heath Insurance Coverage with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Reset
FOR CLERK’S USE ONLY
NOTICE OF YOUR RIGHTS ABOUT
HEALTH INSURANCE COVERAGE
WHEN A PETITION FOR DISSOLUTION (DIVORCE)
IS FILED (A.R.S. §20-1377 AND §20-1408(J))
Petitioner
____________________________
Respondent
____________________________
Case # ____________________________
WARNING:
THIS IS AN IMPORTANT LEGAL NOTICE. YOUR RIGHTS TO HEALTH INSURANCE
COVERAGE COULD BE AFFECTED AFTER YOUR DIVORCE IS FINAL. READ THIS NOTICE CAREFULLY.
IF YOU DO NOT UNDERSTAND THIS NOTICE, YOU SHOULD CALL AN ATTORNEY FOR ADVICE ABOUT
YOUR LEGAL RIGHTS AND OBLIGATIONS.
IMPORTANT INFORMATION IF YOU ARE ON YOUR SPOUSE’S INSURANCE PLAN: When a Petition for
Dissolution of Marriage (papers for a divorce decree) is filed, you and/or your children may continue to be covered
under your spouse’s health insurance policy. Arizona law allows the dependent spouse and/or children to
continue to be covered, but you must take some steps to protect your rights.
WHAT INSURANCE COVERAGE APPLIES TO YOU, AND HOW TO GET IT: If you are covered by your
spouse’s health insurance, and you want to continue to be covered after the divorce is final, you must contact the
insurance company as soon as possible, and you must start to pay the monthly insurance premium within 31
days of the date the insurance would otherwise stop.
If you decide you want to be covered, the insurer can choose whether to continue coverage under the current
policy, or to change the policy to your name. If the policy is changed to your name, it is called a “converted”
policy. If the policy is converted by the insurer, the insurer must provide to you the same or the most similar level
of coverage available, unless you ask for a lower level of coverage.
WHAT COVERAGE APPLIES TO YOUR CHILDREN: If you choose to continue coverage as a dependent
spouse, you can also choose to continue coverage for your dependent children if you are responsible for their
care or support.
PREEXISTING CONDITIONS OR EXCLUSIONS FROM INSURANCE COVERAGE: Whether the insurance is
continued or converted, the insurance must be provided to you without proof of insurability and without exclusions
for coverage other than what was previously excluded before the insurance was continued or converted.
LIMITS ON RIGHTS TO INSURANCE COVERAGE FOR YOU AND YOUR CHILDREN: You may not be entitled
to continued or converted coverage if you are eligible for Medicare or for coverage by other similar types of
insurance which together with the continued coverage would make you over-insured. However, dependent
children of a person who is eligible for Medicare may be covered by a continuance or a conversion. If you have
questions about coverage, check with the insurer and/or the spouse’s employer.
WARNING TO THE SPOUSE FILING THE PETITION FOR DISSOLUTION (DIVORCE): This Notice must be
served on your spouse together with the Petition for Dissolution, the Summons, and the Preliminary
Injunction.
Page 1 of 1
Revised: 5/24/2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Fis 2288 - Michigan Prior Authorization Request Form For Prescription Drugs - Department Of Insurance And Medical Services
Legal
Va Form 4597b - Your Rights To Appeal Our Decision On Your Motion For Review For Clear And Unmistakable Error
Legal
Related Categories
Parent category: Legal