Page 80 - QCS.19 SPD - HSA

Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory, or write to the Division of Technical Assistance and
Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W.
Washington, DC 20210. You may also obtain certain publications about your rights and responsibilities under
ERISA by calling the publications hotline of the Employee Benefits Security Administration at (866) 444-3272.
The Plan's Benefits are administered by QUEEN CITY SKILLED CARE LLC, the Plan Administrator. The Claims
Administrator, United Healthcare Services Inc. or its affiliate or designee is the Claims Administrator and
processes claims for the Plan and provides appeal services; however, the Claims Administrator and QUEEN
CITY SKILLED CARE LLC are not responsible for any decision you or your Dependents make to receive
treatment, services or supplies, whether provided by a Network or Out-of-Network provider. The Claims
Administrator and QUEEN CITY SKILLED CARE LLC are neither liable nor responsible for the treatment,
services or supplies provided by Network or Out-of-Network providers.

Page 75 Section 14 - Important Administrative Information: ERISA
HSA - 2017