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An hufepEndeni Liu.n.ec of the ST OP LOSS PROPOSAL FOR <br /> Mire Cross anti Byre Shield hsso.iaticr., Indian River County BOCC <br /> • HIPAA Privacy rules permit the release of Protected Health Information(PHI)for the purpose of evaluating and accepting risk associated with the <br /> Plan Sponsor as pari of'Health care operations" HMIG will use this information solely for the purpose of evaluating and accepting the risk and <br /> will not disclose any PHI collected except to perform this risk evaluation. <br /> • The rates and factors in this proposal are based on the disclosure of all individuals considered a special enrollee due to having previously satisfied <br /> the plan's lifetime maximum. Written acceptance by HM must be acknowledged before terms of coverage for such individuals are included under <br /> HM's stop loss policy <br /> Any stop loss policy issued by us may be rescinded or re-underwritten if any information requested in connection with this proposal was <br /> intentionally concealed or misrepresented by or on behalf of the Applicant and/or the Applicant's Agent,or if the Applicant and/or the Applicant's <br /> Agent commits fraud. <br /> • As used above: An"Agent"is the Applicant's representative,including but not limited to,the agent,producer or broker of record,or Claims <br /> Administrator. The'Applicant'is the entity,or that entity's authorized representative,that has contracted with us to provide stop loss coverage. A <br /> 'Claims Administrator"is a third party administrator(TPA)designated by the Applicant and approved by us. "Claim Information"consists of <br /> Complete Details of the data requested by us in connection with this proposal following a Diligent Review,such information includes but is not <br /> limited to Know or potential catastrophic claims,large claims and/or shock losses. "Complete Details'includes the name,social security number <br /> (or unique identifier),date of birth,diagnosis,prognosis(unless prognosis cannot be obtained due to reasons beyond your or your Claims <br /> Administrator's control)of the plan's participants and the name of the provider providing treatment to any such participant covered by or eligible for <br /> coverage. A'Diligent Review"consists of a complete review by you,and/or your Claims Administrator and/or your Agent prior to the date Known <br /> or potential catastrophic claims,large claims and/or shock losses are requested by us in connection with this proposal. 'Disclosure"consists of <br /> Complete Details and any other documentation requested by us in connection with this proposal following a Diligent Review including but not <br /> limited to census information and Claim Information. We consider information in connection with this proposal"Known'if,prior to the date or <br /> dates we request such information(including but not limited to Disclosure and Claim Information)a reasonable person can assume that you, <br /> and/or your Claims Administrator and/or your Agent had knowledge of any information that affects or may affect the administration or underwriting <br /> of any coverage issued following acceptance of coverage by us. <br /> ! .,._'11C�r.:..,.i'1:1 iV'lil(i 1l ( !tE l!i�f`•i! .:X;i'jL)! .. I- z r 4 - .• <br /> t :(i!f(� if!!I!t;! V:I t'i.i i', i.i•„ �lire li�cil:!^il`;':t.(i!tI::" '!k;'+!t[' '1i; !-;��. {�;;;I c; <br /> . ' - 'r, Iii; <br /> pruvid!fvi only agli!i!i .l!.3il et;58i"tl�;r.5 <br /> 4.✓�:,., ! (1. <br /> ;A r 5 <br /> 59 <br />