Application for waiver of the pre-existing condition waiting period

You can use this form if you have an individual health insurance policy and qualify for a waiver of the 180-day waiting period during which pre-existing conditions aren’t covered by your health insurance policy.

What you’ll need:

• Your enrollee ID card
• A Certificate of Creditable Coverage from your previous insurance company to show proof of 18 months of continuous health care coverage
• If applicable, a letter from your employer or COBRA administrator explaining why you weren’t eligible for COBRA coverage
• If applicable, a letter from your employer-sponsored health plan or COBRA administrator explaining that you’ve exhausted your COBRA coverage
• A printer to print the form
• An envelope and postage to mail the form, or a fax machine. Each form includes instructions on where to send it.

How to apply:

1. Print the Application for Waiver of Pre-Existing Waiting Period (PDF).
2. Fill out and sign the Application for Waiver of Pre-Existing Waiting Period.
3. Send us the application and any additional documentation by mail or fax.

For more information, please contact us.

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