{COVERED ENTITY NAME} ALTERNATIVE MEASURES Purpose: This Form is used to document the health plan’s alternative measures for an Addressable Implementation Specification that was not adopted. Retain this form in records for at least six the health plan’s (6) years from the date below. Implementation Risk of Not Cost of Benefit of Feasibility of Comments / Specification Implementing? Implementing? Implementing? Implementing? Conclusions (if implementing Alternative, describe how implementing) Name of Security Official: _______________________________________________________________ Signature: Date: QB\21427351.1
{COVERED ENTITY NAME} ALTERNATIVE MEASURES Purpose: This Form is used to document the health plan’s alternative measures for an Addressable Implementation Specification that was not adopted. Retain this form in the health plan’s records for at least six (6) years from the date below. Implementation Specification Risk of Not Implementing? Cost of Implementing? Benefit of Implementing? Feasibility of Implementing? Comments / Conclusions (if implementing Alternative, describe how implementing) Name of Security Official: _______________________________________________________________ Signature: Date: QB\21427351.1