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PLEASE PRINT. For address and/or primary care physician changes call (518) 6413700, 18007772273, or visit www.cdphp.comUSE BLACK INK ONLY. Enrollment Application/Change Form EMPLOYER USE Validate
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Step 1: Gather all relevant information, including the start and end dates of the coverage period.
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Step 4: Provide details about the coverage period, such as the start and end dates.
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Date coverage is effective refers to the date when the insurance coverage becomes active.
Employers or insurance providers are required to file date coverage is effective.
Date coverage is effective should be filled out by providing the specific date when the insurance coverage starts.
The purpose of date coverage is effective is to indicate when the insurance coverage begins for an individual or group.
The specific date when the insurance coverage becomes active must be reported on date coverage is effective.
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