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The Employer hereby authorizes and directs the Claim Administratorto disclose to HCFA peri- <br /> odically,the information identified below pertaining to Medicare-eligible Covered Persons un- <br /> der the Plan. The Employer further agrees to cooperate, and to require and facilitate its em- <br /> ployees cooperation, in supplying to the Claim Administrator the following information. <br /> Information on Medicare-Eligible Covered Persons <br /> • Beneficiary Name <br /> • Date of Birth <br /> • Sex <br /> • Social Security Number <br /> • Health Insurance Claim Number (e.g., Medicare Number) <br /> • Relationship to Employee(e.g., Employee,spouse of Employee,child of Employee, <br /> other relationship to Employee) <br /> • Reason for Medicare Entitlement (e.g., age, disability or ESRD) <br /> Information on Employee <br /> • Employee Name <br /> • Social Security Number , <br /> • Individual Certificate Number of Employee I <br /> • Current Employment/Retirement Status �i <br /> • Coverage Effective Date I <br /> • Coverage Termination Date <br /> • Group Plan Number <br /> • Benefits Provided (e.g., Hospital only, medical benefits only} <br /> • Coverage (e.g., individual, family, family but not spouse) <br /> Information on the Employer <br /> • Name and address of employer that pays the bill for coverage <br /> The Employer agrees that the Claim Administrator's ability to make accurate primary/second- <br /> ary MSP determinations depends on the breadth and accuracy of the Claim Administrator's <br /> files concerning Covered Persons. The Employer agrees to use best efforts in responding <br /> promptly and accurately to the Claim Administrator's requests for information and to require <br /> and facilitate its employees' cooperation in responding promptly and accurately to such re- <br /> quests. <br /> Further, to assure the continuing accuracy of the Claim Administrator's files, the Employer <br /> agrees that it is the Employer's responsibility to notify the Claim Administrator promptly of any <br /> change in the size of the Employer's work force or status of its employees that might effect <br /> the order of payment underthe MSP statute,such as information regarding working-aged per- <br /> - . sons who retire and changes in the size of the Employer's work force that place it in, or take <br /> it out of, the scope of the MSP statute. If the Claim Administrator does not receive such in- <br /> formation from the Employer,the Claim Administrator will assume that all relevant factors re- <br /> main unchanged and will process claims accordingly. The group acknowledges and agrees <br /> that the Claim Administrator will be using the information provided by the Employer and Cov- <br /> - 14 - <br />