Download How to Complete Plan Sponsor Certification of Group Health Plan

How to Complete Plan Sponsor Certification of Group Health Plan HIPAA, Compliance
and Authorization for Third Party Access to PHI Form
Page 1- Top of form
Complete requested information. The Group Health Plan Name only pertains to ERISA groups with a
different name for ERISA purposes. If this does not pertain to your group, please leave blank.
Page 1- Bottom of form
 The Group Decision Maker must always sign the bottom of the form.
 The Broker Agency Decision Maker - needs to sign the form if the Agency is requesting “Broker All”.
Exhibit A - Section A
Requests access for the Group Benefit Administrator(s) or other group representatives. Example: Enrollment
& Billing, Consultants, Vendor, etc.
 Complete the requested information.
 Complete Security questions if Online Services is being requested
 Representative must sign at the red arrow in Section A
 The Group Owner/Decision Maker completes the level of PHI access for this representative in Section D
 The Group Owner/Decision Maker needs to signs Section E
 Additional representatives can be added using Exhibit B. (Use the same format)
Exhibit A – Section B
This section requests access for all individual broker representatives of the group.
 Complete the requested information
 Sign at the red arrow. Example: Representative 1, sign as Representative 1
 The Group Owner/Decision Maker needs to complete the level of PHI access for this Representative
in Section D
 The Group Owner/Decision Maker needs to signs Section E.
Exhibit A – Section C
This section requests access for all agents within the Broker Agency to have access to the groups PHI.
 Broker Agency Decision Maker competes the requested information
 Broker Agency Decision Maker signs on the bottom of Page 1.
 Group Owner/Decision Maker completes the level of PHI access in Section D and signs in Section E
Exhibit A – Section D
Group Owner Decision Maker chooses the level of PHI access for each representative
Exhibit A – Section E
Group Owner Decision Maker signs to authorize all levels of PHI access
Exhibit B
This is an addendum for additional Group or Non-broker representatives. Use the instructions in
Exhibit A, Section A to complete.