NOTICE OF PRIVACY PRACTICES

Effective: April 1, 2009
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.

Introduction

In order to provide insurance coverage and/or health plan administrative services, we must obtain and maintain Protected Health Information (PHI). This privacy notice describes the types of information that is collected and your rights regarding how that information can be used.

PHI is individually identifiable health information that is created or received by your provider, your health plan or insurer, a data clearinghouse, a health authority, employer, school or university. PHI can be maintained or transmitted in any form or medium.

It relates to the past, present or future:

• condition of your physical or mental health,
• health care provided to you; or
• payment for the health care provided to you.

PHI does not include summary health information or information that has been de-identified according to the standards for de-identification provided for in the HIPAA Privacy Rule.

Permitted/Required Use and Disclosure of Your PHI for Treatment, Payment and Health Care Operations

Your PHI will be used and disclosed for the purpose of routine treatment, payment and health care operations. Examples of routine treatment, payment and health care operations include, but are not limited to:

• payment for treatment of your health condition(s);
• enrollment into the health plan;
• eligibility for coverage and plan benefits;
• claims administration;
• payment of claims;
• premium billing;
• underwriting;
• business planning and development;
• actuarial pricing, studies and review;
• complaint review; and
• regulatory review and legal compliance.

Use and Disclosure for Treatment

Your PHI may be used by, and disclosed to, health care providers including, but not limited to, doctors, nurses, laboratory technicians, medical students and other health care personnel involved in your treatment.

Use and Disclosure for Payment 

Your PHI may be used by, and disclosed to, individuals involved in the collection of your premium and the payment of your benefits. The use and disclosure also includes verification of participation in the plan, eligibility for plan benefits and premium adjustments due to changes in health status and/or individual demographics. Your PHI may be shared with persons involved in utilization review, including pre-certification, pre-authorization, and concurrent and retrospective review, to assist in reimbursement of health care claims or other claims payment or collection procedures.

Use and Disclosure for Health Care Operations

Your PHI may be used and disclosed for plan operation purposes including, but not limited to: underwriting; premium rating; submitting claims; placing a contract for reinsurance of risk relating to claims for health care, including stop-loss and excess loss insurance; quality review assessments; audits, including fraud and abuse detection and compliance programs; business management and planning; the sale, transfer, merger or consolidation of a covered entity; and legal or administrative services. In addition, your PHI may be used and disclosed for case management, and care coordination, contacting of health care providers and patients with information about treatment, drug and disease management alternatives and other related functions that do not include treatment.

We may share this information with our business associates for purposes of utilization reviews, appropriateness of care reviews, peer review for resolution of grievances, consultation with outside health care providers, consultants and attorneys. We require our business associates to sign an agreement specifying their compliance with our privacy and security policies.

We have developed privacy and security policies and procedures in order to ensure the privacy of your PHI. These policies and procedures are based on appropriate administrative, technical and physical safeguards necessary to maintain confidentiality. Access to your PHI is limited to those individuals that have a legitimate business need for that information. This protection extends to the use of your PHI by our business associates.

Other Permitted/Required Uses and Disclosures of PHI

We may release your personal information to your employer for workers’ compensation purposes, or for automobile insurance claims. We will only use or disclose the minimum amount necessary to perform these other functions.

Disclosures may be made to:

• the health plan sponsor for payment or other claim purposes, such as coordination of benefits;
• organ donation and tissue transplant entities, if you are an organ or tissue donor;
• the military if you are a member of the armed services;
• worker’s compensation carriers; and
• correctional institutions if you are an inmate.

We, or one of our approved business associates, may use or disclose your PHI in order to provide you with the following information:

• prescription drug alternatives;
• treatment alternatives;
• other health related benefits and services that may be of interest to you;
• public health agencies;
• law enforcement personnel in response to legal requirements;
• coroners, medical examiners, funeral directors;
• legal representative in response to a court order or other legal proceeding; and
• national security and intelligence agencies as authorized by law.

Other Uses and Disclosures of PHI

Uses and disclosures of PHI for purposes other than treatment, payment or health care operations will be made only with your written authorization. If you provide us authorization to use or disclose your PHI, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose information following the specific purpose contained in the authorization. You understand that we are unable to take back any disclosures already made with your authorization, and that we are required to retain any records we may have containing your PHI. If you revoke your authorization for payment or health care operations, you may jeopardize the administration of the benefits under your health plan.

Your Individual Rights With Respect to PHI

Upon written request, you have the right to:

• request restrictions on certain uses and disclosures of your PHI. We are not required to agree to a requested restriction.
• receive confidential communication of PHI.
• access our records containing descriptions of your PHI.
• request an amendment to your PHI. We are not required to agree to a requested amendment.
• receive an accounting of unauthorized disclosures made regarding PHI.

Unless specifically requested otherwise, we will communicate PHI in connection with treatment, payment or health care operations, with any person covered under the plan. Should any covered person want a restriction on such disclosure of PHI, they must request such restriction in writing. Although we are not required to agree to a requested restriction, we will consider all factors explained in the request.

Except for uses and disclosures associated with Treatment, Payment, or Health Care Operations, we do not use or disclose PHI when specifically protected by more stringent state law. Examples of more stringent state laws include those protecting HIV status, results of genetic testing, and indications of domestic abuse. We will follow state privacy laws that are more stringent than this federal law.

If you have chosen to receive this privacy notice electronically, you may also receive a paper copy from us upon your request.

Our Duties Regarding the Use and Disclosure of Your PHI

We are committed to maintaining your privacy and are required:

• by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI;
• to abide by the terms of the Notice of Privacy Practices currently in effect.

We reserve the right to change the terms of this privacy notice, and have such change be effective for all PHI that is maintained. Notification of a revised privacy notice will be provided through one of the following:

• U.S. Postal Service;
• Revised Plan Document;
• Internet E-mail.

Up to date privacy notices are maintained on our Website.

How to File a Complaint Regarding the Use and Disclosure of Your PHI

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of Health and Human Services. All complaints must be in writing. Please be assured that you may not be retaliated against for filing a complaint.

How to Contact Us

You may contact our representative at the following:

Cheryl Smith, Privacy Officer
Village of Hicksville
111 South Main Street
Hicksville, OH 43526
hixcs@defnet.com