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A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L.. BUTLER, CLERK Schedule C-1 EMPLOYER'S CERTIFICATION To EXHIBIT C HIPAA BUSINESS ASSOCIATE AGREEMENT ADDENDUM PART 1 — Employer to Amend Plan Documents for Privacy Provisions Employer certifies that Employer has amended the Plan's Plan Document to incorporate the provisions required by 45 C.F.R. § 164.504(f)(2), as set forth below, and agrees to comply with the Plan's Plan Document as amended. 1. Neither use nor further disclose Protected Health Information, except as permitted or required by the Plan's Plan Document or as required by law. 2. Neither use nor disclose Protected Health Information for any employment-related action or decision, or in connection with any other benefit or employee benefit plan of Employer. 3. Ensure adequate separation between Employer and the Plan by (a) describing those employees or classes of employees or other persons under Employer's control who will be given access to Protected Health Information to perform plan administration functions for the Plan, (b) restricting the access to and use of Protected Health Information by such employees or other persons to the plan administration functions that Employer will perform for the Plan, and (c) instituting an effective mechanism for resolving any noncompliance with the Plan's Plan Document by such employees or other persons. 4. Ensure that any subcontractor or agent to which Employer provides Protected Health Information agrees to the restrictions and conditions of the Plan's Plan Document with respect to Protected Health Information. 5. Report to the Plan any use or disclosure of Protected Health Information of which Employer becomes aware that is inconsistent with the uses and disclosures allowed by the Plan's Plan Document. 6. Make Protected Health Information available to the Plan or, at the Plan's direction, to the Member who is the subject of Protected Health Information (or the Member's Personal Representative) so that the Plan can meet its access obligations under 45 C.F.R. § 164.524. 7. Make Protected Health Information available to the Plan for amendment and, on notice from the Plan, amend Protected Health Information, so that the Plan can meet its amendment obligations under 45 C.F.R. § 164.526. 8. Record Disclosure Information as defined above for each disclosure that Employer makes of Protected Health Information that is not excepted from disclosure accounting and provide that Disclosure Information to the Plan on request so that the Plan can meet its disclosure accounting obligations under45 C.F.R. § 164.528. 23