Certification of ________________________

WHERE AS The Company is the sponsor of an employee welfare benefit plan for its employees and their dependents; and
WHERE AS The Company’s employee welfare benefit plan is a “group health plan” within the meaning of the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and
WHERE AS The Company provides health insurance coverage to the participants and beneficiaries in the the company group health plan; and
WHERE AS The Company’s desire to exchange health information protected under HIPAA (“protected health information” or “PHI”) for purposes related to administration of the group health plan;
THEREFORE BE IT RESOLVED, that the Company hereby certifies to the following, as required by Section 45 CFR 164.504(f) of HIPAA:
The Company’s Summary Plan Description documents that govern the Company’s group health plan have been amended to incorporate the following provisions and The Company agrees to:
- not use or further disclose PHI other than as permitted or required by the Plan documents or as required by law;
- ensure that any agents, including subcontractors, to whom it PHI has been provided to agree to the same restrictions and conditions that apply to The Company with respect to such PHI;
- not use or disclose PHI for employment-related actions and decisions unless authorized by the affected individual;
- not use or disclose PHI in connection with any other benefit or employee benefit plan of The Company , unless authorized by the affected individual;
- report to The Company designee any PHI use or disclosure that it becomes aware of which is inconsistent with the uses or disclosures provided for;
- make PHI available to an individual based on HIPAA’s access requirements;
- make PHI available for amendment and incorporate any PHI amendments based on HIPAA’s amendment requirements;
- make available the information required to provide an accounting of disclosures;
- make its internal practices, books and records relating to the use and disclosure of PHI received from source available to the Secretary of the U.S. Department of Health and Human Services to determine the Health Plan’s compliance with HIPAA;
- ensure that adequate separation between the insurance carrier and The Company is established as required by HIPAA (45 CFR 164.504(f)(2)(iii)); and
- if feasible, return or destroy all PHI received from the insurance carrier that The Company maintains in any form and retain no copies of such PHI when no longer needed for the specified disclosures to those purposes that make the return or destruction infeasible.IN WITNESS WHEREOF, this Certification is hereby executed this_________day of ____________, 2003.
 
___________________________       _______________________
On behalf of the Plan Sponsor Title:    Privacy Official
 
 
 
Back to HIPAA
Memorandum
Notice of Privacy Practices
Certification of Plan-sample
Authorization for release of Health Information-sample
Individual Request to inspect health information-sample
Log of Medical Disclosures-sample
Acceptance of Appointment
Term Notice