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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />RYAN L. BUTLER, CLERK <br />Schedule C-2 (f.k.a. Exhibit 3) <br />to EXHIBIT C <br />HIPAA BUSINESS ASSOCIATE AGREEMENT ADDENDUM <br />DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PLAN <br />ADMINISTRATION <br />The Plan must promptly notify BCBSF in writing if any of the information contained in this <br />Schedule C-2 changes. <br />PART 1 <br />Name(s) and Title(s) of Employer representatives (i.e., employees of Employer) <br />authorized by the Employer to request and receive Summary Health Information from <br />BCBSF to perform Plan administrative functions: <br />PART 2 <br />Identify the name(s), title(s), and company name(s) of any individual(s) from other <br />Business Associates of the Plan that Employer, on behalf of the Plan, hereby authorizes <br />to request and receive Protected Health Information: <br />Company Name 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 />Employer acknowledges and agrees that, for purposes of these types of disclosures to <br />third parties, BCBSF may require the Business Associate of the Plan to enter into a <br />confidentiality and indemnification agreement with BCBSF in a form acceptable by <br />BCBSF. BCBSF may require the Employer and/or the Plan to be a party to this <br />agreement. <br />PART 3 <br />The Employer, on behalf of the Plan, affirms that all authorization forms that may be <br />required from the Plan's Members authorizing the use and/or release of protected or other <br />confidential personal health information by BCBSF or its Designated Agent in order to <br />perform its obligations under the Agreement have been obtained. <br />25 <br />