CHIP Coverage Coordination Disclosure Form

This document is about a draft CHIP Coverage Coordination Disclosure Form issued under various sections of law, including the Children's Health Insurance Program Reauthorization Act of 2009 and ERISA. The form is intended to be completed by the plan administrator and provide information to the issuing state on the group health plan eligibility, benefits, and premiums for an employee, in order to coordinate CHIP coverage. The form includes various sections for the issuing state information, employee information, group health plan eligibility and enrollment status, benefits offered, and plan administrator contact information.