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This form is intended to be used if you are applying for either a change in coverage start date or a change in coverage termination date for your Nevada Health Link health insurance coverage. Coverage change date requests are subject to Exchange approval.

Requests that do not comply with 45 C.F.R. 155.430 which indicates requests for retro-terminations must be requested within 14 days of the desired termination date. Requests that fall out of the specific regulations will be denied by Nevada Health Link.

Please use this form to clearly explain why your request should be considered, particularly any factors that show an error or mistake in your current or planned coverage effective dates, please be specific.

Please avoid providing any information directly related to private medical conditions.

  • To Request a Change in Coverage Start Date

  • To Request a Change Termination Date

  • Max. file size: 80 MB.
  • Requests that do not comply with 45 C.F.R. 155.430 which indicates requests for retro-terminations must be requested within 14 days of the desired termination date. Requests that fall out of the specific regulations will be denied by Nevada Health Link.

Notice of Privacy Practices

Nevada Health Link is committed to maintaining the privacy and security of personally identifiable information. Nevada Health Link will use personally identifiable information only as permitted by Nevada Health Link’s policies and as required by law.

More information about Nevada Health Link’s privacy and security practices and your rights is available on Nevada Health Link’s website at Nevada Health Link’s Privacy Policy

If you need help understanding this form in another language, or if you are disabled and need help to use this form, please contact Nevada Health Link. There is no cost for assistance.

To complete via PDF: Effective Date Change Request Save this file to your computer, fill out the section that’s related to your life event, and email this form to: customerserviceNVHL@exchange.nv.gov. If you need more space, you may include an additional document or sheet.

Effective Dates Change Request (Spanish)

 

State of Nevada

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Review the Silver State Health Insurance Exchange Nondiscrimination Statement in English or en Español.