Buffalo City School District Employee Health Insurance Enrollment Form Page 11
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15EMPLOYEE ACKNOWLEDGEMENT
COBRA
Under the Consolidated Omnibus Reconciliation Act (COBRA) of 1985, temporary group health
insurance continuation plan is available to you and covered members of your family should you
lose health insurance coverage through the District. COBRA requires employers to offer eligible
persons who lose group health plan coverage, the opportunity to continue their group health
insurance coverage at their own expense.
I acknowledge receipt of COBRA information and if married, I will discuss this notice with my
spouse and other family members. I am aware that the complete COBRA Initial Notice is
available on-line at .
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires group
health plans to notify you about their policies and practices governing the confidentiality of your
medical information. These policies and practices are first effective beginning April 14, 2003.
Each Plan’s privacy policy and practices protect confidential medical information that identifies
you and relates to a physical or mental health condition or the payment of your health care
expenses. This individually identifiable medical information is known under HIPAA as
“protected health information” (“PHI”).Your PHI will not be used or disclosed by any Plan
without a written authorization from you, except as described in the Plan’s Notice or as
otherwise permitted by federal and state medical information privacy laws.
I acknowledge receipt of HIPAA information from the Buffalo Board of Education. If married, I
will discuss this notice with my spouse and other family members. I am aware that the complete
Plan Notice is available on-line at .
EMPLOYEE RESPONSIBILITY
I understand that it is my responsibility, as an employee of the Buffalo Board of Education,
to notify the Benefits Office within 30 days of any life changing event, such as divorce, death
or the aging off of dependent children. I further understand that failure to do so, could result in
unwarranted premium payments or submission of claims for ineligible dependents. In the case of
events, such as marriage, birth and adoption, failure to report within 30 days will result in a
delayed effective date of the additional coverage.
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