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Plan Sponsor's HIPAA Privacy <br />Rule Certification Form <br />I, , on behalf of Elk River Municipal Utilities, am <br />(OH'ner, or Ofl7cer Name) <br />authorized to make the following certification for each of the employee benefits plans. <br />1. The Plan Sponsor will not further use or disclose protected health information (PHI) <br />except as required by the plan documents or by law. <br />2. The Plan Sponsor will ensure that the Plan Sponsors' agents and subcontractors <br />comply with the Employer's HIPAA Privacy Policy. <br />3. The Plan Sponsor will not use or disclose the PHI for employment-related actions or <br />decisions. <br />4. The Plan Sponsor will not use or disclose the PHI in connection with any other <br />benefit or employee benefit plan of the sponsor except as permitted under HIPAA. <br />5. The Plan Sponsor will self-report any disclosure violations to the plan. <br />6. The Plan Sponsor will meet certain administrative requirements applicable to <br />health plans. <br />7. The Plan Sponsor will make its internal practices, books and records related to use <br />and disclosure of PHI received from the plan available to the Secretary of Health <br />and Human Services for compliance review. <br />8. Where feasible, the Plan Sponsor will return or destroy all PHI received from the <br />plan when done with it. <br />9. The Plan Sponsor will maintain adequate separation between the group health plan <br />and the sponsor. <br />Signature of Owner or Officer <br />Date <br />Name of Employee Benefit Plan sponsored by Employer: Elk River Municipal Utilities <br />Medical Health Plan, Long Term Disability Plan, Life Insurance Plan. <br />