Laserfiche WebLink
EXHIBIT 3— DISCLOSURE OF PROTECTED HEALTH INFORMATION <br />FOR PLAN ADMINISTRATION <br />Group Health Plan ("GHP") must promptly notify Administrator in writing if any of the <br />information contained in EXHIBIT 3 changes. <br />PART 1 <br />Name(s) and Title(s) of Employer representatives (i.e. employees of Employer) authorized to <br />request and receive the minimum necessary Protected Health Information from Administrator: <br />for the performa <br />indicated by GH] <br />• Actuarial <br />('laim�/rr <br />Exhibit 3 to be executed separately <br />• Quality assessment and improvement activities <br />• Performance monitoring <br />• Other health care operations <br />• Payment activities <br />PART 2 <br />otherwise <br />Identify the name(s), title(s) and company name(s) of any individual(s) from organizations other <br />than Employer or Group Health Plan ("GHP") (examples of such "GHP Vendor" types of services <br />include, but are not limited to, stop -loss carriers; reinsurers; agents, brokers or consultants; or <br />external auditors) that Employer or GHP hereby authorizes to request and receive the minimum <br />necessary Protected Health Information to perform plan administration functions and/or assist with <br />the procurement of reinsurance or stop -loss coverage: <br />Company Name <br />Type of Service Name of Individual Title of Individual <br />Performed (Example: Performing Service Performing Service <br />stop -loss carrier, <br />reinsurer, agent, <br />broker <br />PART 3 <br />GHP affirms that all authorization forms that may be required from GHP's participants <br />authorizing the use and/or release of protected or other confidential personal health information <br />by BlueCross and B1ueShield of Florida or its Designated Agent in order to perform its <br />obligations under the Agreement have been obtained. <br />52 <br />