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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 information contained in <br /> EXHIBIT 3 changes . <br /> PART 1 <br /> Name(s) and Title(s) of Employer representatives (i .e. employees of Employer) authorized to request and receive <br /> the minimum necessary Protected Health Information from Administrator: <br /> Joe Baird County Administrator <br /> Ann Rankin Benefits / Pavroll Administrator <br /> Donna Kaspari Director of Human Resources <br /> Jason Brown Budget Director <br /> for the performance of the following plan administration functions for GHP unless otherwise indicated by GHP : <br /> • Actuarial and statistical analysis <br /> • Claims/membership inquiries <br /> • Procurement of reinsurance or stop loss coverage <br /> • Quality assessment and improvement activities <br /> • Performance monitoring <br /> • Other health care operations <br /> • Payment activities <br /> PART 2 <br /> Identify the name(s) , title(s) and company name(s) of any individual(s) from organizations other than Employer or <br /> Group Health Plan ("GHP") (examples of such "GHP Vendor" types of services include, but are not limited to, <br /> stop-loss carriers ; reinsurers ; agents, brokers or consultants; or external auditors) that Employer or GHP hereby <br /> authorizes to request and receive the minimum necessary Protected Health Information to perform plan <br /> administration functions and/or assist with the procurement of reinsurance or stop-loss coverage : <br /> Company Name Type of Service Performed Name of Individual Title of Individual <br /> (Example: stop-loss carrier, Performing Service Performing Service <br /> reinsurer, agent, broker <br /> Crowne Consulting Group Agent/Broker Leslie Karp Director of Acct. <br /> Management <br /> Crowne Consulting Group Agent/Broker Mackie Branham CEO <br /> Crowne Consulting Groqp Agent/Broker Ray Tomlinson President <br /> Safeco Life Insurance �," Re-insurer Murphy Head Regional Group Manager <br /> Company <br /> 18 <br /> HIPAA\BA Amend to ASO Agmt - fini <br /> August 12, 2004 <br />