Gap Report Template

Note: Benefit Transition Date no sooner than April 1, 2024

  • Template is also available in the following formats: XLSX & PDF
PLAN NAME: [Insert Plan Name]
[Insert Site Name] [Insert Tax ID] [Insert Sponsor Name] [Insert Date]
Enrollee Last Name: First Name: Middle Initial: CIN (Medicaid Number): Gender: Date of Birth: Street Address: City: Zip Code: Phone Number: Area of Service: Service Period: Service Notes: (As Needed) Number of Gaps: PCP Name: PCP Phone Number: Last Service by PCP:
Doe Jane A XX11111Y Female 1/1/2010 123 Main Street City 99999 888–888–8888 WCV 1/1/2016–1/1/2017 2 Dr. Mary Cunningham 333–333–3333 3/3/2016
Doe Jane A XX11111Y Female 1/1/2010 123 Main Street City 99999 888–888–8888 Immunizations 1/1/2016–1/1/2017 2 Dr. Mary Cunningham 333–333–3333 3/3/2016
Smith Joe B AA00000B Male 5/5/2005 555 First Street Town 88888 777–777–7777 Dental 1/1/2016–1/1/2017 1 Dr. James Stevens 444–444–4444 4/4/2015