United Way of Greater Cleveland -- Nonprofit Resources

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Documents for Participating Agencies

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Administration Manual

Table of Contents

Manual Section I - VI

Manual Section VII - XII

Exhibit 1 - Enrollment Form

Exhibit 2 - Med Life Evidence of Insurance Form

Exhibit 3 - Employee Waiver Statement

Exhibit 3A - Notice of Special Enrollment Rights

Exhibit 3B - Notice Requirement Log

Exhibit 3F - Women's Health Act Notice

Exhibit 4 - HIPAA Special Enrollment Form

Exhibit 5 - Guidelines for Administering a QMCSO

Exhibit 6 - Med Life Waiver of Premium Form

Exhibit 7 - Employee Medical Insurance Election Form

Exhibit 8 - Spouse Medical Insurance Election Form

Exhibit 8ABC - Medicare Primary Payer Rules

Exhibit 9 - Notice of Documentation of Health Coverage

Exhibit 10 - Certificate of Group Health Plan Coverage

Exhibit 10A - HIPAA Statute

Exhibit 10F - HIPAA Authorization Requirements

Exhibit 10Fa - HIPAA Authorization Requirements Exhibit

Exhibit 10G - Sample Authorization Tracking Form

Exhibit 10Ha - CIGNA Notice of Privacy

Exhibit 10Hb - HIPAA Notice of Privacy

Exhibit 10Hc - Medical Mutual Notice to Insureds

Exhibit 10He - QualChoice Notice of Privacy

Exhibit 11 - Initial COBRA Notice

Exhibit 12 - COBRA Rights Notice

Exhibit 12A - COBRA Enrollment Form

Exhibit 12B - Notice to Health Care Provider of COBRA Coverage

Exhibit 12C - COBRA Exhaustion Notice

Exhibit 12D - Unavailability of Health Care Coverage Notice

Exhibit 12E - Enrollment Form

Exhibit 13 - Med Life Application to Convert Group Life Insurance

Exhibit 13A - Med Life Application for Portability

Exhibit 14 - Roster Billing

Exhibit 14A - Roster Billing (Example)

Exhibit 15 - Medical Mutual Claim Form

Exhibit 15A - Medical Mutual Rx Drug Card Claim Form

Exhibit 15B - Medical Mutual Direct Rx Claim Form

Exhibit 16 - Medical Mutual Dental Claim Form

Exhibit 17 - Medical Mutual Vision Claim Form

Exhibit 18 - Med Life Death Claim Form

Exhibit 19 - Medical Mutual Application for Continuation of Coverage-Disability

Exhibit 20 - Request for Supplies

Exhibit A - 2004 Participation Agreement

Exhibit B - Summary of Rules Governing Plan 2004

Exhibit C - 2004 Participating Agency Plan Election Form

Exhibit D - 2004 Compliance Checklist

Exhibit E - Annual Participation Fees 2004