THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
READ IT CAREFULLY.
April 14, 2003
(“Covered Entity”) as described in the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder, commonly
known as HIPAA. HIPAA requires
Covered Entity by law to maintain the privacy of your personal health
information and to provide you with notice of Covered Entity’s legal duties
and privacy policies with respect to your personal health information.
We are required by law to abide by the terms of this Privacy Notice.
personal health information from you through treatment, payment and related
healthcare operations, the application and enrollment process, and/or healthcare
providers or health plans, or through other means, as applicable.
Your personal health information that is protected by law broadly
includes any information, oral, written or recorded, that is created or received
by certain health care entities, including health care providers, such as
physicians and hospitals, as well as, health insurance companies or plans. The
law specifically protects health information that contains data, such as your
name, address, social security number, and others, that could be used to
identify you as the individual patient who is associated with that health
or Disclosures of Your Personal Health Information
we may not use or disclose your personal health information without your
permission. Further, once your
permission has been obtained, we must
use or disclose your personal health information in accordance with the specific
terms that permission. The
following are the circumstances under which we are permitted by law to use or
disclose your personal health information.
your consent, we may use or disclose
your personal health information in order to provide you with services and the
treatment you require or request, or to collect payment for those services, and
to conduct other related health care operations otherwise permitted or required
by law. Also, we are permitted to
disclose your personal health information within and among our workforce in
order to accomplish these same purposes.
However, even with your permission, we are still required to limit such
uses or disclosures to the minimal amount of personal health information that is
reasonably required to provide those services or complete those activities.
of treatment activities include:
(a) the provision, coordination, or management of health care and related
services by health care providers; (b) consultation between health care
providers relating to a patient; or (c) the referral of a patient for health
care from one health care provider to another.
of payment activities include:
(a) billing and collection activities and related data processing; (b) actions
by a health plan or insurer to obtain premiums or to determine or fulfill its
responsibilities for coverage and provision of benefits under its health plan or
insurance agreement, determinations of eligibility or coverage, adjudication or
subrogation of health benefit claims; (c) medical necessity and appropriateness
of care reviews, utilization review activities; and (d) disclosure to consumer
reporting agencies of information relating to collection of premiums or
of health care operations include:
development of clinical guidelines; (b) contacting patients with information
about treatment alternatives or communications in connection with case
management or care coordination; (c) reviewing the qualifications of and
training health care professionals; (d) underwriting and premium rating; (e)
medical review, legal services, and auditing functions; and (f) general
administrative activities such as customer service and data analysis.
Required By Law
may use or disclose your personal health information to the extent that such use
or disclosure is required by law and the use or disclosure complies with and is
limited to the relevant requirements of such law.
Examples of instances in which we are required to disclose your personal
health information include: (a) public health activities including,
preventing or controlling disease or other injury, public health surveillance or
investigations, reporting adverse events with respect to food or dietary
supplements or product defects or problems to the Food and Drug Administration,
medical surveillance of the workplace or to evaluate whether the individual has
a work-related illness or injury in order to comply with Federal or state law;
(b) disclosures regarding victims of abuse, neglect, or domestic violence
including, reporting to social service or protective services agencies; (c)
health oversight activities including, audits, civil, administrative, or
criminal investigations, inspections, licensure or disciplinary actions, or
civil, administrative, or criminal proceedings or actions, or other activities
necessary for appropriate oversight of government benefit programs; (d) judicial
and administrative proceedings in response to an order of a court or
administrative tribunal, a warrant, subpoena, discovery request, or other lawful
process; (e) law enforcement purposes for the purpose of identifying or locating
a suspect, fugitive, material witness, or missing person, or reporting crimes in
emergencies, or reporting a death; (f) disclosures about decedents for purposes
of cadaveric donation of organs, eyes or tissue; (g) for research purposes under
certain conditions; (h) to avert a serious threat to health or safety; (i)
military and veterans activities; (j) national security and intelligence
activities, protective services of the President and others; (k) medical
suitability determinations by entities that are components of the Department of
State; (l) correctional institutions and other law enforcement custodial
situations; (m) covered entities that are government programs providing public
benefits, and for workers’ compensation.
Other Situations, With Your Specific Authorization
as otherwise permitted or required, as described above, we may not use or
disclose your personal health information without your written authorization.
Further, we are required to use or disclose your personal health
information consistent with the terms of your authorization.
You may revoke your authorization to use or disclose any personal health
information at any time, except to the extent that we have taken action in
reliance on such authorization, or, if you provided the authorization as a
condition of obtaining insurance coverage, other law provides the insurer with
the right to contest a claim under the policy.
We may contact
you to provide appointment reminders or information about treatment alternatives
or other health-related benefits and services that may be of interest to you.
We may contact you to raise funds for Covered Entity.
If we are a group health plan or health insurance issuer or HMO with
respect to a group health plan, we may disclose your personal health information
to be sponsor of the plan.
you have certain rights with respect to your personal health information.
The following is a brief overview of your rights and our duties with
respect to enforcing those rights.
To Request Restrictions On Use Or Disclosure
You have the
right to request restrictions on certain uses and disclosures of your personal
health information about yourself. You
may request restrictions on the following uses or disclosures: to carry out
treatment, payment, or healthcare operations; (b) disclosures to family members,
relatives, or close personal friends of personal health information directly
relevant to your care or payment related to your health care, or your location,
general condition, or death; (c) instances in which you are not present or your
permission cannot practicably be obtained due to your incapacity or an emergency
circumstance; (d) permitting other persons to act on your behalf to pick up
filled prescriptions, medical supplies, X-rays, or other similar forms of
personal health information; or (e) disclosure to a public or private entity
authorized by law or by its charter to assist in disaster relief efforts.
we are not required to agree to any requested restriction, if we agree to a
restriction, we are bound not to use or disclose your personal healthcare
information in violation of such restriction, except in certain emergency
situations. We will not
accept a request to restrict uses or disclosures that are otherwise required by
To Receive Confidential Communications
You have the
right to receive confidential communications of your personal health
information. We may require written
requests. We may condition the
provision of confidential communications on you providing us with information as
to how payment will be handled and specification of an alternative address or
other method of contact. We may require that a request contain a statement that
disclosure of all or a part of the information to which the request pertains
could endanger you. We may not
require you to provide an explanation of the basis for your request as a
condition of providing communications to you on a confidential basis. We must
permit you to request and must accommodate reasonable requests by you to receive
communications of personal health information from us by alternative means or at
alternative locations. If we are a
health care plan, we must permit you to request and must accommodate reasonable
requests by you to receive communications of personal health information from us
by alternative means or at alternative locations if you clearly state that the
disclosure of all or part of that information could endanger you.
To Inspect And Copy Your Personal Health Information
record set is a group of records we maintain that includes Medical records and
billing records about you, or enrollment, payment, claims adjudication, and case
or medical management records systems, as applicable.
You have the right of access in order to inspect and obtain a copy your
personal health information contained in your designated record set, except
for (a) psychotherapy notes, (b) information complied in reasonable
anticipation of, or for use in, a civil, criminal, or administrative action or
proceeding, and (c) health information maintained by us to the extent to which
the provision of access to you would be prohibited by law.
We may require written requests. We
must provide you with access to your personal health information in the form or
format requested by you, if it is readily producible in such form or format, or,
if not, in a readable hard copy form or such other form or format. We may provide you with a summary of the personal health
information requested, in lieu of providing access to the personal health
information or may provide an explanation of the personal health information to
which access has been provided, if you agree in advance to such a summary or
explanation and agree to the fees imposed for such summary or explanation. We
will provide you with access as requested in a timely manner, including
arranging with you a convenient time and place to inspect or obtain copies of
your personal health information or mailing a copy to you at your request. We will discuss the scope, format, and other aspects of your
request for access as necessary to facilitate timely access.
If you request a copy of your personal health information or agree to a
summary or explanation of such information, we may charge a reasonable
cost-based fee for copying, postage, if you request a mailing, and the costs of
preparing an explanation or summary as agreed upon in advance. We reserve the
right to deny you access to and copies of certain personal health information as
permitted or required by law. We
will reasonably attempt to accommodate any request for personal health
information by, to the extent possible, giving you access to other personal
health information after excluding the information as to which we have a ground
to deny access. Upon denial of a
request for access or request for information, we will provide you with a
written denial specifying the legal basis for denial, a statement of your
rights, and a description of how you may file a complaint with us.
If we do not maintain the information that is the subject of
your request for access but we know where the requested information is
maintained, we will inform you of where to direct your request for access.
To Amend Your Personal Health Information
any other requests or for further information regarding the privacy of your
personal health information, and for information regarding the filing of a
complaint with us, please contact our privacy officer Ms. Gordon at
the address, telephone number, or e-mail address listed above.