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IMPORTANT PROVISIONS THIS COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM ("EVIDENCE OF COVERAGE" ) CONSTITUTES ONLY A SUMMARY OF THIS PLAN. THE GROUP AGREEMENT BETWEEN OCCUPATIONAL HEALTH SERVICES, INC. ( "OHS") , AND THE EMPLOYER THAT HAS SPONSORED YOUR PARTICIPATION IN THIS PLAN ("EMPLOYER" ) MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF COVERAGE. YOU MAY REQUEST TO SEE THE GROUP AGREEMENT FROM EMPLOYER. Not all words and terms used in this Evidence of Coverage have their usual meanings and some have meanings that limit their application. Please refer to the "Definitions" Section to understand the meanings of these words and terms. By enrolling or accepting services under this plan, Members are obligated to understand and abide by all terms, conditions and provisions of the Group Agreement and this Evidence of Coverage. If this Evidence of Coverage has been issued to an existing OHS group, then it replaces the former Evidence of Coverage, effective upon the date set forth in the Group Agreement. Read this Evidence of Coverage as benefits may have changed from those stated within the Evidence of Coverage for the previous period of coverage. This Evidence of Coverage, the Group Agreement and benefits of this plan are subject to amendment in accordance with the provisions of the Group Agreement without the consent or concurrence of Members. The services described in this Evidence of Coverage are Covered Services only if and to the extent they (1) are provided by Participating Providers, and (2) have obtained Prior Authorization of coverage and referral by OHS. This plan will not pay charges for services and supplies provided by non-Participating Providers. Members are obligated to inform OHS as to any change in residence and any circumstance which may affect entitlement to coverage or eligibility under this plan. Members must also immediately disclose to OHS whether they have filed a workers' compensation claim, or were injured by a third party. Health, legal and certain other types of professionals are required under law to treat their client's problems confidentially. Common exceptions to confidentiality include mandatory reporting of child abuse, elder abuse, persons dangerous to themselves or others. OHS will preserve the confidentiality of patient-related records in its possession in accordance with the requirements of applicable federal - 1 - '" "'"""'-'''..-''.'''''''''''' '