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Direct Bill Client Profile <br />Employer Information <br />Company Name: DBA (Doing Business As) Federal Tax ID Number - FEIN <br />City of Santa Ana 95-6000785 <br />Address <br />20 Civic Center Plaza M-34, P.O. Box 1988 M-34 <br />CityState Zip <br />Santa Ana CA 92702-1988 <br />Employee/Direct Bill Counts <br />Number of Employees Eligible for Number of Eligible Employees as Number of Employees Covered by Number of Current Direct Bill <br />Benefits: of (date): Benefits: Continuants: <br />301 11/14/2013 301 139 <br />Business Rules <br />Direct Billing will include (check all that apply) <br />® Retiree ® Surviving Souse ❑ Leave of Absence(including LTD&STD ❑ Other <br />What is the payment grace period? <br />How many days after the payment grace period before participants <br />(All premiums are due the first of the month) <br />are cancelled? (payment deadline) <br />❑ 30 days from due date ❑ 60 days from due date ® Other 10 <br />❑ 30 days ® 60 days ❑ 90 days ❑ Other <br />days <br />How will cancellations be processed? <br />❑ Automatic (The CONEXIS system cancels participants if they have not paid by the deadline date) <br />® Manual (Participants are canceled manually by request of the client. <br />Should CONEXIS mail cancellation letters to participants? <br />® Yes ❑ No <br />HIPAA Authorized Contact List for Direct Bill Services <br />The following Named Contacts List identifies all individuals to whom CONEXIS may provide protected health information (PHI) in the <br />performance of its duties as set forth in the Confidentiality Exhibit of the Administrative Services Agreement. <br />All individuals requiring access to the CONEXIS Web site must be included on the list below or access to the CONEXIS Web Site will <br />not be granted. <br />Contact Name <br />Title <br />Property <br />Phone <br />E-mail <br />Web Access <br />Affiliation <br />Benefits <br />ORead Only 2 Update ❑ No Access <br />Kathleen Crook <br />Supervisor <br />714 647 - 6967 <br />kcrook Santa-ana.or <br />Personnel <br />[]Read Only ® Update ❑ No Access <br />Norma Buckley <br />Specialist <br />714 647 - 5443 <br />nbuckley@santa-ana.org <br />Personnel <br />❑Read Only ® Update ❑ No Access <br />Itzia Carvajal <br />Specialist <br />714 647 - 5474 <br />icarvpjal@santa-ana.org <br />Payroll <br />[]Read Only ® Update ❑ No Access <br />Systems <br />Haney Mostafa <br />Analyst <br />1714 647-5490 <br />hmostafa Santa-ana.or <br />[]Read Only ❑ Update -El -No Access <br />[]Read Only ❑ Update El No Access <br />[]Read Only ❑ Update ❑ No Access <br />Direct Bill Premiums <br />Which contact person listed above is the recipient of the monthly Direct Bill premiums? Kathleen Crook, Benefits Supervisor <br />— Form <br />Name�1-M/ee�t Title - Phone Number <br />Crook—Benefits Supervisor (714) 647 - 6967 <br />