UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
Each time you visit a
hospital, physician, dentist, or other healthcare provider, a record of your
visit is made. Typically, this record contains your symptoms, examination and
test results, diagnoses, treatment, and a plan for future care or
treatment. This information often
referred to as your health or medical record, serves as a basis for planning
your care and treatment and serves as a means of communication among the many
health professionals who contribute to your care. Understanding what is in your record and how your health
information is used helps you to ensure its accuracy, better understand who,
what, when, where, and why others may access your health information, and helps
you make more informed decisions when authorizing disclosure to others.
YOUR HEALTH INFORMATION RIGHTS
Unless otherwise required by law, your health record is the physical
property of the health plan that compiled it.
However, you have certain rights with respect to the information. You have the right to:
1.
Receive a copy of this
Notice of Privacy Practices from us
upon enrollment or upon request.
2.
Request restrictions
on our uses and disclosures of your protected health information for treatment, payment and health care operations. However, we reserve the right not to agree
to the requested restriction.
3.
Request to receive
communications of protected health information in confidence.
4.
Inspect and obtain a
copy of the protected health information
contained in your medical and billing records and in any other of the
organization’s records used by us to make decisions about you. A reasonable copying charge may apply.
5.
Request an amendment
to your protected health information. However, we may deny your request for an
amendment, if we determine that the protected health information or record that
is the subject of the request:
· was not created by us, unless you provide a reasonable
basis to believe that the originator of the protected health information is no
longer available to act on the requested amendment;
· is not part of your medical or billing records;
· is not available for inspection as set forth above; or
· is accurate and complete.
In any event, any agreed
upon amendment will be included as an addition to, and not a replacement of,
already existing records.
6.
Receive an accounting
of disclosures of protected health information made by us to individuals or entities other than to
you, except for disclosures:
· to carry out treatment, payment and health care
operations as provided above;
· to persons involved in your care or for other
notification purposes as provided by law;
· to correctional institutions or law enforcement
officials as provided by law;
· for national security or intelligence purposes;
· that occurred prior to the date of compliance with
privacy standards (April 14, 2004 for small health plans);
· incidental to other permissible uses or disclosures;
· that are part of a limited data set (does not contain
protected health information that directly identifies individuals);
· made to plan participant or covered person or their
personal representatives;
· for which a written authorization form from the plan
participant or covered person has been received
7.
Revoke your
authorization to use or disclose health information except to the extent that we have already been taken
action in reliance on your authorization, or if the authorization was obtained
as a condition of obtaining insurance coverage and other applicable law
provides the insurer that obtained the authorization with the right to contest
a claim under the policy.
HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED
This
organization may use and/or disclose your medical information for the following
purposes:
Treatment: We
may use or disclose your health information without your permission for health
care providers to provide you with treatment.
Payment: We
may use or disclose your health information without your permission to carry
out activities relating to reimbursing you for the provision of health care,
obtaining premiums, determining coverage, and providing benefits under the
policy of insurance that you are purchasing.
Such functions may include reviewing health care services with respect
to medical necessity, coverage under the policy, appropriateness of care, or
justification of charges.
To
Carry Out Certain Operations Relating to Your Benefit Plan: We also may use
or disclose your protected health information without your permission to carry
out certain limited activities relating to your health insurance benefits,
including reviewing the competence or qualifications of health care
professionals, placing contracts for stop-loss insurance and conducting quality
assessment activities.
To
Plan Sponsor: Your protected health
information may be disclosed to the plan sponsor as necessary for the
administration of this health benefit plan pursuant to the restrictions imposed
on plan sponsors in the plan documents.
These restrictions prevent the misuse of your information for other
purposes.
Health-Related
Benefits and Services: We may contact
you to provide information about other health-related products and services
that may be of interest to you. For
example, we may use and disclose your protected health information for the
purpose of communicating to you about our health insurance products that could
enhance or substitute for existing health plan coverage, and about
health-related products and services that may add value to your existing health
plan.
Individuals
Involved in Your Care or Payment for Your Care: Unless you object, we may disclose your protected
health information to your family or friends or any other individual identified
by you when they are involved in your care or the payment for your care. We will only disclose the protected health
information directly relevant to their involvement in your care or payment. We
may also disclose your protected health information to notify a person
responsible for your care (or to identify such person) of your location,
general condition or death.
Business Associates: There may be some services provided in our organization through
contracts with Business Associates. An
example might include a copy service we use when making copies of your health
record. When these services are
contracted, we may disclose some or all of your health information to our
Business Associate so that they can perform the job we have asked them to do.
To protect your health information, however, we require the Business Associate
to appropriately safeguard your information.
Limited
Data Sets: We
may use or disclose, under certain circumstances, limited amounts of your
protected health information that is contained in limited data sets. These circumstances include public health,
research, and health care operations purposes.
Organ
and Tissue Donation: If you are an
organ donor, we may release medical information to organizations that handle
organ procurement or organ, eye or tissue transplantation or to an organ
donation bank, as necessary to facilitate organ or tissue donation and
transplantation.
Worker's
Compensation: We may release protected
health information about you for programs that provide benefits for work
related injuries or illness.
Communicable
Diseases: We may disclose protected health information to notify a person
who may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition.
Health
Oversight Activities: We may disclose
protected health information to federal or state agencies that oversee our
activities.
Law
Enforcement: We may disclose protected
health information as required by law or in response to a valid judge ordered
subpoena. For example in cases of
victims of abuse or domestic violence; to identify or locate a suspect,
fugitive, material witness, or missing person; related to judicial or
administrative proceedings; or related to other law enforcement purposes.
Military
and Veterans: If you are a member of
the armed forces, we may release protected health information about you as
required by military command authorities.
Lawsuits
and Disputes: We may disclose
protected health information about you in response to a court or administrative
order. We may also disclose medical information about you in response to a
subpoena, discovery request, or other lawful process.
Inmates: If you are an inmate of a correctional institution or
under the custody of a law enforcement official, we may release protected
health information about you to the correctional institution or law enforcement
official. An inmate does not have the
right to the Notice of Privacy Practices.
Abuse
or Neglect: We may disclose protected
health information to notify the appropriate government authority if we believe
a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you
agree or when required or authorized by law.
Coroners,
Medical Examiners, and Funeral Directors: We may release protected health information to a coroner or medical
examiner. This may be necessary to
identify a deceased person or determine the cause of death. We may also release
protected health information about patients to funeral directors as necessary
to carry out their duties.
Public
Health Risks: We may disclose your
protected health information for public health activities and purposes to a
public health authority that is permitted by law to collect or receive the
information. The disclosure will be made for the purpose such as controlling
disease, injury or disability.
Serious
Threats: As permitted by applicable
law and standards of ethical conduct, we may use and disclose protected health
information if we, in good faith, believe that the use or disclosure is
necessary to prevent or lessen a serious and imminent threat to the health or
safety of a person or the public.
Food
and Drug Administration (FDA): As
required by law, we may disclose to the FDA health information relative to
adverse events with respect to food, supplements, product and product defects,
or post marketing surveillance information to enable product recalls, repairs,
or replacement.
For
Purposes For Which We Have Obtained Your Written Permission: All other
uses or disclosures of your protected health information will be made only with
your written permission, and any permission that you give us may be revoked by
you at any time.
INFORMATION WE COLLECT ABOUT YOU
We
collect the following categories of information about you from the following
sources:
·
Information that we
obtain directly from you, in conversations or on applications or other forms
that you fill out.
·
Information that we
obtain as a result of our transactions with you.
·
Information that we
obtain from your medical records or from medical professionals.
·
Information that we
obtain from other entities, such as health care providers or other insurance
companies, in order to service your policy or carry out other insurance-related
needs.
OUR RESPONSIBILITIES
We are required to maintain
the privacy of your health information.
In addition, we are required to provide you with a notice of our legal
duties and privacy practices with respect to information we collect and
maintain about you. We must abide by
the terms of this notice. We reserve
the right to change our practices and to make the new provisions effective for
all the protected health information we maintain. If our information practices change, a revised notice will be
mailed to the address you have supplied upon request. If we maintain a Web site that provides information about our
services or benefits, the new notice will be posted on that Web site. Your health information will not be used or
disclosed without your written authorization, except as described in this
notice. Except as noted above, you may revoke your authorization in writing at
any time.
OUR PRACTICE REGARDING CONFIDENTIALITY
AND SECURITY
We restrict access to
nonpublic personal information about you to those employees who need to know
that information in order to provide products or services to you. We maintain
physical, electronic, and procedural safeguards that comply with federal
regulations to guard your nonpublic personal information.
NOTICE OF PRIVACY PRACTICES AVAILABILITY
You will be provided a hard
copy for review at the time of enrollment (or on the Privacy compliance date
for this health plan). Thereafter, you
may obtain a copy upon request, and the notice will be maintained on the
organization’s Web site (if applicable Web site exists) for downloading.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions about
this notice or would like additional information, you may contact our Privacy
Officer at the telephone or address below.
If you believe that your privacy rights have been violated, you have the
right to file a complaint with the Privacy Officer or with the Secretary of the
Department of Health and Human Services.
We will take no retaliatory action against you if you make such
complaints.
The contact information for
both is included below.
U.S. Department of Health and Human
Services
Office of
the Secretary
200
Independence Avenue, S.W.
Washington, D.C. 20201
Tel: (202) 619-0257
Toll Free: 1-877-696-6775
http://www.hhs.gov/contacts
Motheral Printing Company
Employee Benefit Health Plan
Pat Thomas,
Privacy Officer
4251 Empire Rd. Fort Worth, TX 76155
817/335-1481
817/868-2753
FAX
Motheral Printing Company
Employee Benefit Health Plan
NOTICE OF PRIVACY PRACTICES
EFFECTIVE DATE: April 14, 2004
|
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. |