Group Name: / Authorized Person*:

* Person notated here is authorized on this account to make changes to the authorized user list.

User
Access / Group / Div #: / Last name: / First Name: / Access level:
See attached matrix for explanation of access rights / FOR HDS USE ONLY

USER ID

/

Temp Password

New
Remove / 0 1 2 5 1011
11152025 30
Email address:
New
Remove / 0 1 2 5 1011
11152025 30
Email address:
New
Remove / 0 1 2 5 1011
11152025 30
Email address:
New
Remove / 0 1 2 5 1011
11152025 30
Email address:
New
Remove / 0 1 2 5 1011
11152025 30
Email address:
New
Remove / 0 1 2 5 1011
11152025 30
Email address:

I certify and covenant as follows: I am the authorized agent of the above employer group ("Group"), which allows me access to HDS Online for purpose of approving the above user(s) to transmit eligibility data and authorize payment to HDS via the Internet. Group shall be fully responsible for the accuracy and timeliness of all information transmitted on HDS Online and for timely transmission to HDS of all required premiums for Group. Group shall maintain all subscriber signatures and up-to-date eligibility related information on file for transactions processed through HDS Online. Group shall notify HDS Membership Services immediately if any previously designated authorized user is terminated or no longer has authorized access to HDS Online, so proper security measures can be made to terminate said user’s access. Group shall be solely responsible for assuring compliance with all privacy laws and rules by Group's employees and agents regarding all information maintained and transmitted regarding Group's HDS Plan. Group shall defend, indemnify and hold harmless HDS from any and all claims, damages, and expenses of any nature arising from any breach or alleged breach regarding these certifications and covenants.

Authorized Signature / Name (Print) / Phone Number /

Date

Explanation of Access Levels

View Only / Limited Update to Address & ID Card request / All Access / No access
Description / Eligibility & Billing Invoice / Payment Options / All
Level 0 / Level 1 / Level 2 / Level 5 / Level 10 / Level 11 / Level 15 / Level 20 / Level 25 / Level 30
Eligibility / Maintain Enrollment Information / Enrollment
Address
ID Card
Billing / Reprocess Billing Invoices / Billing Invoice
Payment / Set-up/Manage Banking Information / Manage Payment Accts
Authorize Payments / Make Payment
LEVEL / DESCRIPTION
0 / View Billing
1 / View Eligibility & Billing
2 / View Eligibility & Billing; View Payment Accounts
5 / View Eligibility & Billing; Update Address and ID Cards
10 / UpdateEligibility, View Billing
11 / View Eligibility, Update Billing
15 / UpdateEligibility, Update Billing
20 / View Billing; Make Payments
25 / View Billing; Make Payments; Manage Payment Accounts
30 / Update Eligibility & Billing, Make Payments; Manage Payment Accounts