|
|
 |
|
 |
Important Information / Health Insurance Portability & Accountability Act |
|
|
 |
NOTICE OF PRIVACY PRACTICES
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.
EFFECTIVE APRIL 14, 2003
We are required by the privacy regulations issued under the Health Insurance Portability
and Accountability Act of 1996 (“HIPAA”) to maintain the privacy of our Plan’s
customers' Protected Health Information hereinafter referred to as Medical Information
and to provide those customers with notice of our legal duties and privacy practices with
respect to your Medical Information. If your state provides privacy protections that are
more stringent than those provided by HIPAA, we will maintain your Medical Information
in accordance with the more stringent state standard.
This Notice applies to “Medical Information” associated with “Health Plans” issued by:
• American Heritage Life Insurance Company
This Notice describes how we may use and disclose Medical Information to perform
claims handling, payment, general insurance operations, and for other purposes that
are permitted or required by law.
We may change the terms of this Notice at any time. If we change this Notice, we may
make the new notice terms effective for all of your Medical Information that we maintain, including any information we created or received prior to issuing the new notice. If we do revise our Privacy Notice, copies will be sent to you if you are then currently insured under our Plan.
Medical Information means information about you that is created or received by us and
during the administration of coverage under the Plan, which identifies you or for which
there is a reasonable basis to believe the information can be used to identify you and
that relates to:
1) the past, present or future physical or mental health condition of the individual; or
2) the provision of health care to the individual; or
3) the past, present or future payment for the provision of health care to the individual.
Uses and Disclosures of Medical Information With Your Written Authorization
Except as described in the next section of this Notice, we will not use or disclose your
Medical Information for any purpose unless you have signed a form authorizing the use
or disclosure. You have the right to revoke that authorization in writing at any time.
However, any action already taken by the Plan or others in reliance on the authorization
cannot be changed.
Uses and Disclosures of Medical Information Without Your Written Authorization
For Payment. We may make use of and disclose your Medical Information without your
written authorization as may be necessary for payment purposes. For example, we
may use information regarding your medical procedures and treatment to process and
pay claims or certify these services are covered under your Plan.
For Plan Administrative Operations. We may make use of and disclose your Medical
Information without your written authorization as necessary for our Plan administrative
operations. Plan administrative operations include our usual business activities,
examples of which are management, licensing, peer review, quality improvement and
assurance, enrollment, underwriting, reinsurance, compliance, auditing, rating, claims
handling, complaint handling and other functions related to your Plan.
To Individuals Involved In Your Care. We may, without your written authorization, for
the purposes of treatment, payment or Plan administrative operations, disclose the fact
that you are covered under a Plan or that payment has been processed to a family
member, other relative, your close personal friend or any other person you may identify. In these circumstances, we would not disclose any Medical Information which is not directly relevant to that person’s involvement with your care or with payment for your care.
If you have designated a person to receive information regarding payment of the
premium or pay premium via credit card, we may inform that person or credit card
facility when your premium has not been paid or received by us.
We may also disclose limited Medical Information to a public or private entity that is
authorized to assist in disaster relief efforts in order for that entity to locate a family
member or other persons that may be involved in some aspect of caring for you.
To Our Business Associates. Certain aspects and components of our services are
performed through contracts with outside persons or organizations. Examples of these
may include, but are not limited to our duly appointed insurance agents, financial
auditors, reinsurers, legal services, enrollment and billing services, claim payment and
medical management services. We may provide access to your Medical Information
without your written authorization to one or more of these outside persons or
organizations who assist us with payment or Plan administrative operations. We require
these business associates to appropriately safeguard the privacy of your information.
For Other Products and Services. We may contact you without your written
authorization to provide information regarding Plan upgrades or additional benefits that
may be of interest to you. For example, we may use the fact that you currently are
insured under a Plan for the purpose of communicating to you about changes to our
Plan or products that could enhance or add value to existing coverage.
For Disclosure With Authorization. Unless otherwise excluded in this notice, we will
not disclose any other Medical Information to any person or entity not specifically
mentioned elsewhere in this Notice without your express written authorization.
For Other Uses and Disclosures. We are permitted or required by law to make some
other uses and disclosures of your Medical Information without your authorization:
• We may release your Medical Information if required by law to a government
oversight agency conducting audits, investigations, or civil or criminal proceedings.
• We may release your Medical Information if required to do so by a court or
administrative ordered subpoena or discovery request. In most cases you will
have notice of such a release.
• We may release your Medical Information for public health activities, such as
required reporting of disease, injury, birth and death and for required public health
investigations.
• We may release your Medical Information as required by law if we suspect child
abuse or neglect or if we believe you to be a victim of abuse, neglect or domestic
violence.
• We may disclose your Medical Information to the Food and Drug Administration if
necessary to report adverse events, product defects or to participate in product
recalls.
• We may release your Medical Information to law enforcement officials as required
by law to report wounds, injuries or crimes.
• We may release your Medical Information to coroners and/or funeral directors
consistent with law.
• We may release your Medical Information for a national security or intelligence
activity or, if you are a member of the military, as required by the armed forces.
• We may release your Medical Information to workers' compensation agencies if
necessary for your workers' compensation benefit determination.
Your Rights
Right to Inspect and Copy Your Medical Information. You may have access to our
records that contain your Medical Information in order to inspect and obtain copies of
the records. Under limited circumstances, we may deny you access to a portion of your
records. If you desire access to your records, please obtain a record request form from
our Privacy Officer and submit the completed form to our Privacy Office. If you request
copies, we may charge you copying and mailing costs.
Right to Amend Your Medical Information. You have the right to request that we
amend your Medical Information maintained in our enrollment, payment, claims
adjudication and case or medical management records, or other records we use to
make decisions about you. If you desire to amend these records, please obtain an
amendment request form from our Privacy Office and submit the completed form to our
Privacy Office. We will comply with your request unless special circumstances apply. If
your physician or other health care provider created the information that you desire to
amend, you should contact the provider to amend the information.
Right to an Accounting of the Disclosures of Your Medical Information. Upon
request, you may obtain an accounting of certain disclosures of your Medical
Information made by us on or after April 14, 2003, excluding disclosures made earlier
than six years before the date of your request. If you request an accounting more than
once during any 12 month period, we will charge you a reasonable fee for the
subsequent accounting statements.
Right to Request Confidential Communications. We will accommodate your
reasonable request to receive communications of your Medical Information from us by
alternative means of communication or at alternative locations if the request clearly
states that disclosure of that information could endanger you.
Right to Request Restrictions on Use and Disclosure of Your Medical Information.
You have the right to request restrictions on some of our uses and disclosures of your
Medical Information for medical treatment, payment, or Plan administrative operations
by notifying us of your request for a restriction in writing mailed to the contact identified
at the end of this Notice. Your request must describe in detail the restriction you are
requesting. We are not required to agree to your restriction request but will attempt to
accommodate your requests. We retain the right to terminate an agreed-to restriction.
In the event of a termination of an agreed-to restriction by us, we will notify you of such
termination, but the termination will only be effective for Medical Information we receive
after we have notified you of the termination. You also have the right to terminate any
agreed-to restriction by contacting us using the “Contact Information” provided at the
end of this Notice.
Personal Representatives. You may exercise your rights through a personal
representative who will be required to produce evidence of his or her authority to act on
your behalf. Proof of authority may be made by a notarized power of attorney, a court
order of appointment of the person as your legal guardian or conservator, or if you are
the parent of a minor child. We reserve the right to deny access to your personal
representative.
Right to Receive Paper Copy of this Notice. You may obtain a copy of this Notice.
You may obtain a paper copy of this Notice even if you agreed to receive such notice
electronically. Please contact us and we will mail it to you.
Complaints
If you believe your privacy rights have been violated, you can file a complaint with the
Plan or with the Secretary of the U.S. Department of Health and Human Services. To
file a complaint with the Plan, send it in writing to the “Contact Information” at the
address listed at the end of this Notice. There will be no retaliation for filing a complaint.
You may obtain a copy of this Notice by writing to us at the contact address below.
Contact Information
If you have questions or need further assistance regarding this Notice, you may contact:
Allstate Workplace Division
Attn: HIPAA Privacy Officer
1776 American Heritage Life Drive
Jacksonville, Florida 32224
Or, you may telephone the Customer Care Center at 1-800-521-3535.
|
|
|
|
