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HIPAA Plan Sponsor (employer) Certification Form

_______ nOption1:ThePlanSponsorchoosesnottoreceivenorallowtheirAgent,Broker,or (Initial) ConsultanttoreceivePHIfromAvMedwiththeexceptionofSummaryHealthInformation (subjecttoemployermembershiplevelswithAvMed)andPlanParticipationinformation. AnyadditionalPHImayonlybeobtainedbysubmittinganAvMedPHIAuthorizationRelease Formcompletedbythecoveredindividualwhoseinformationisbeingreleased.

_______ nOption2:ThePlanSponsorchoosestoreceivePHIandcomplywithallofthefollowing: (Initial) (IfthePlanSponsorchoosestoauthorizeanAgent,BrokerorConsultanttoalsoreceivePHI fromAvMed,thePlanSponsormustcomplywithallofthefollowingaswellasallthe requirementsontheattachedHIPAAPlanSponsor/BusinessAssociateCertificationForm) HIPAArequiresthatinorderforafullyinsuredPlanSponsortoreceiveProtectedHealth Information(PHI)fromAvMedHealthPlantheymustfirstcertifythattheirBenefitPlan Documentshavebeenamendedtoincludethefollowing: 1. HowthePHIwillbeusedordisclosedandthatsuchusesordisclosuresarepermittedby thePrivacyRule; 2. ThatthePlanSponsorwillnotuseorfurtherdisclosethePHIexceptasallowedbythePlan Documentsorasotherwisepermittedbylaw; 3. ThatanyagentsorsubcontractorsofthePlanSponsorthatreceivePHIwillcomplywithall oftherestrictionssetoutinthePlanDocuments; 4. ThattheSponsorwillnotuseordisclosetheinformationforemployment-relatedactionsand decisions; 5. ThattheSponsorwillnotuseordisclosetheinformationinconnectionwithanyotherbenefitsoremployeeBenefitPlansofthePlanSponsor; 6. ThatthePlanSponsorwillreporttotheBenefitPlananyusesordisclosuresoftheinformationthatareinconsistentwiththeusesordisclosuresallowedbytheRule; 7. ThatthePlanSponsorwillamendanyinaccurateinformationasrequiredbythePrivacy Rule; 8. ThatthePlanSponsorwillmakeavailableanyinformationthatmayberequiredinorderto provideindividualswithanaccountingoftheusesanddisclosuresoftheirPHIasrequired bythePrivacyRule; 9. ThattheSponsorwillmakeitsinternalpractices,books,andrecordsrelatedtotheuseand disclosureofPHIavailabletoHHSforpurposesofdeterminingtheBenefitPlan'scompliancewiththeRule;and 10.That,iffeasible,theSponsorwillreturnordestroyallPHIreceivedfromtheBenefitPlan whenitisnolongerneeded.(45CFR§164.504(f)(2)(ii)). ThePlanSponsorsmustalsocertifytoAvMedthattheirPlanDocumentshavebeenamended toprovideforadequate"separation"betweentheBenefitPlanEntityandthePlanSponsorEntity.Inordertoprovideforthisseparation,thePlanDocumentsmust: 1. DescribetheemployeesorclassesofemployeesorotherpersonsundercontrolofthePlan SponsorthatwillbegivenaccesstoPHI; 2. Restrictaccessto,anduseof,PHIbytheSponsor'semployeesandothersunderthecontroloftheSponsorconsistentwiththePlanDocuments;and 3. ProvideamechanismforresolvinganyissuesofnoncompliancewiththePrivacyRuleby thePlanSponsor'semployeesandothersundercontroloftheSponsor.(45CFR§164.504 (f)(2)(iii)).

Furthermore,thePlanSponsormustidentifytheentityorindividualsdesignatedwithintheBenefitPlanwith whomAvMedmayexchangePHI: NameorTitleofDesignatedIndividual(s): _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Inaccordancewiththeforegoing,______________________________herebycertifiesthatthePlan (NameofPlanSponsor) DocumenthasbeenappropriatelyamendedtosatisfytheHIPAArequirements.

SignaturePlanSponsor/EmployerRepresentative: By:________________________________________ PrintName:_________________________________ Title:_________________________________ Date:_________________________________

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