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“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 Date of this notice: April 14, 2003
This Notice is being directed to all members of Group Health Cooperative of Eau
Claire.
PRIVACY RESPONSIBILITY
This Notice describes how we may collect, use, and disclose your protected health
information and your rights concerning your protected health information. “Protected
health information” is information about you including demographic information collected
from you that can reasonably be used to identify you and that relates to your past,
present, or future physical condition, the provision of health care to you, or the
payment for that care.
Protected health information in this Notice includes information about you that
appears on enrollment applications, claims, prior authorization requests, referral
requests to medical providers, surveys, health care treatment, services and prescriptions,
health care encounter data, service requests, payment information, appeal and grievance
information, and other records received in writing, in person, by telephone, or
electronically (such as your name, address, telephone number, and other demographic
data.)
PRIVACY RESPONSIBILITIES INCLUDE:
Protecting the privacy of and protected health information created or received about
you.
Providing you with this Notice that indicates Group Health Cooperative of Eau Claire’s
privacy policies and the legal duty for those policies.
Using and sharing protected health information as outlined in this Notice.
Notifying you when information within this Notice changes.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Uses and Disclosures for Payment, Health Care Operations and Treatment. We use and
disclose protected health information in a number of different ways in connection
with the payment of your health care, our health care operations, and your treatment.
The following are only a few examples of the types of uses and disclosures of your
protected health information that we are permitted to make without your authorization.
Payment: We will use and disclose your protected health information to administer
your health benefits policy or contract, which may involve the determination of
eligibility, claims payment, utilization review and management, medical necessity
review, coordination of care, benefits and other services, and responding to complaints,
appeals and external review requests. Protected health information may also be shared
with government programs such as Worker’s Compensation, Medicaid, Medicare, and
coordination of benefits with other insurance companies in order to administer your
benefits, and payments.
Health Care Operations: Protected health information may be used or disclosed in
order to perform necessary business activities in relation to your benefits and
services received. These activities include the following: quality and cost improvement
functions such as conducting and arranging medical reviews and accreditation by
independent organizations such as the National Committee for Quality Assurance,
quality improvement surveys and studies, performance measurement and outcomes assessments,
health claims analysis and health services research, operation of preventive health,
early detection and disease and case management and coordination of care programs
including information about treatment alternatives, therapies, health care providers,
settings of care, or other health-related services, underwriting, ratemaking and
administration of reinsurance, stop loss and excess of loss policies, transfer of
policies or contracts, risk management, audit services, quality of care case review,
peer review and credentialing of providers, data and information systems management,
customer service, administrative management, and general administration of your
benefits.
Treatment: Protected health information may be used or disclosed in order to make
sure that you are receiving the medical treatment and services needed. We may disclose
your protected health information to health care providers (doctors, dentists, chiropractors,
pharmacies, hospitals, and other caregivers) who request it in connection with your
medical treatment. We may also disclose your protected health information to health
care providers in connection with preventative health, early detection, and disease
and case management programs.
In connection with foregoing activities, we may collect the following types of information
about you:
Information we receive directly or indirectly from you, your employer, benefit plan
sponsor, or one of their business associates through applications, surveys, or other
forms (e.g., name, address, social security number, date of birth, marital status,
dependent information, employment information and medical history).
Information about your relationships and transactions with us and others (e.g. health
care claims and encounters, medical history, eligibility information, payment information,
and appeal and grievance information).
We may share your protected health information with affiliates and third party “business
associates” that perform various activities for us or on our behalf. Whenever such
arrangement involves the use of disclosure of your protected health information,
we will have a written contract that contains terms designed to protect the privacy
of your protected health information. We may also contact you about treatment alternatives
or other health-related benefits and services that may be of interest to you.
We may disclose protected health information to the plan sponsor to permit the plan
sponsor to perform administrative functions. Please see your plan sponsor information
for a full explanation of the limited uses and disclosures that the plan sponsor
may make of your protected health information in providing plan administrative functions
for your group health plan.
If we obtain protected health information for underwriting purposes and the policy
or contract of health insurance or health benefits is not written with us, we will
not use or disclose that protected health information for any other purpose except
as required by law.
We do not destroy protected health information when individuals terminate their
coverage with us. The information is necessary and used for many of the purposes
described above even after an individual leaves a plan and in many cases is subject
to legal retention requirements. However, the policies and procedures that protect
this information against inappropriate use and disclosure apply regardless of the
status of any member.
Some of the uses and disclosures described in this notice may be limited in certain
cases by applicable state laws that are more stringent than federal laws.
Other Permitted or Required Uses and Disclosures of Protected Health Information
We may use or disclose your protected health information in the following additional
situations without your authorization:
Others Involved in Your Healthcare: Unless you object, we may disclose to a member
of your family, a relative, or any other person that you identify the protected
health information directly relevant to that person’s involvement in your health
care or payment for health care. If you are present for such a disclosure, we will
either seek your verbal agreement to the disclosure or provide you an opportunity
to object to it. We may also make such disclosures to the persons described above
in situations where you are not present or you are unable to agree or object to
the disclosure, if we determine that the disclosure is in your best interest. We
may also disclose your protected health information to an authorized public or private
entity to assist in disaster relief efforts and to coordinate uses and disclosures
to family or other individuals involved in your health care.
Unless we are given an alternative address, we will mail explanations of benefits
forms and other mailings containing protected health information to the address
that we have on record for the subscriber of the policy.
Informing You: Your protected health information may be used to let you know about
health and well being services that are offered by the health plan. This may include
contacting you for appointment reminders, follow-up care surveys, informing you
of treatment alternatives, or providing you with information about health related
benefits and services offered by Group Health Cooperative of Eau Claire.
As Required by Law: Your protected health information may be used or disclosed to
the extent that we are required to do so by law.
Legal Proceedings: We may disclose your protected health information in the course
of any legal proceeding, in response to an order of a court or administrative tribunal,
and, in certain cases, in response to a subpoena, discovery request, or other lawful
processes.
Law Enforcement: We may disclose your protected health information under limited
circumstances to law enforcement officials. For example, disclosures may be made
in response to a warrant or subpoena, or for the purpose of identifying or locating
a suspect, witness or missing persons, or to provide information concerning victims
of crimes.
Public Health: Your protected health information may be reported to a public health
agency to help prevent or control disease, injury, disability, infection exposure,
child abuse, or family violence. In addition, disclosures may be made as required
to the Food and Drug Administration to report adverse events, product defects, product
tracking, to enable product recalls, to make repairs or replacements, or to conduct
product surveillance.
Abuse or Neglect: We may make disclosures to government authorities concerning abuse,
neglect, or domestic violence.
Health Oversight Activities: Your protected health information may be used or disclosed
to a government agency authorized to oversee the health care system or government
programs, or its contractors. Examples include licensing and inspecting of medical
facilities, audits, or other proceedings related to the oversight of the health
care system.
Coroners, Medical Examiners, or Funeral Directors: Protected health information
may be used or disclosed to a medical examiner, coroner, or funeral director as
needed to carry out duties authorized by law. For example, this may be necessary
to identify a deceased person.
For Organ Donations: If you are an organ donor, information may be given to the
organization that locates organs for the purpose of an organ transplantation or
donation.
Worker’s Compensation: Your protected health information may be used or disclosed
to the extent required by worker’s compensation laws.
Public Safety: Your protected health information may be used or disclosed in order
to prevent or lessen a serious threat to your health or safety, to another person,
or the general public.
Military Activity and National Security: If you are a veteran, your protected health
informationmay be used or disclosed as required by veteran administration authorities.
It also may be disclosed to Armed Forces personnel under certain circumstances and
to authorized federal officials for the conduct of national security and intelligence
activities.
Court of Other Hearings / Correctional Institutions: Your protected health information
may be disclosed in order to comply with court orders and other hearings requested
by law. If you are an inmate in a correctional facility, your information may be
disclosed for the provision of health care to you or for the health and safety of
you or others.
Uses and Disclosures of Protected Health Information with an Authorization.
Other uses and disclosures of protected health information will be made only with
your written authorization, unless otherwise permitted or required by law. You may
revoke this authorization, at any time, in writing, except to the extent that we
have taken an action in reliance on the use or disclosure indicated in the authorization.
Please refer to the Contact Information Box for the telephone number and address
for this request.
YOUR PROTECTED HEALTH INFORMATION PRIVACY RIGHTS
The following are additional rights you have in relation to your protected health
information:
Right to Inspect and Copy Your Protected Health Information: You have the right
to see or copy records used to make decisions about your health plan services. It
will not include information needed for civil, criminal, administrative actions
and proceedings, or psychotherapy notes. We may ask that your request be in writing
and to provide us with the specific information we need to fulfill your request.
A fee will be charged to cover the processing and mailing cost of your request.
Please refer to the Contact Information Box for the telephone number and address
for this request.
Right to Correct Your Protected Health Information: You have the right to ask us
to amend enrollment, claim, or other records. All requests for amendments must be
in writing. In certain cases, we may deny your request as we may not have created
the original information. All denials will be made in writing and will indicate
how you can respond if you disagree. Please refer to the Contact Information Box
for the telephone number and address for this request.
Right to Receive a Record of Disclosures of Your Protected Health Information: You
have the right to have us provide you with a list of times when we have disclosed
your protected health information for any purpose other than treatment, payment,
health care operations, national security purposes, or for any listing already provided
to you. All requests must be in writing. We will require you to provide us with
the specific information we need to fulfill your request with specific dates required.
This requirement applies for six years from the date of the disclosure beginning
with dates after April 14, 2003. If you request a list more than once in a 12-month
period, a fee will be charged to cover the processing and mailing cost of your request.
Please refer to the Contact Information Box for the telephone number and address
for this request.
Right to Request Restrictions: You have the right to request restrictions on the
way we use or disclose your protected health information for treatment, payment,
or health care operations. However, we are not required to agree to these restrictions.
All requests must be made in writing. Please refer to the Contact Information Box
for the telephone number and address for this request.
Right to Confidential Communications: You have the right to reasonable requests
to communicate with you about your protected health information by alternative means
or to alternative locations. Your request will be evaluated and you will be notified
if it can be done. All requests must be made in writing. Please refer to the Contact
Information Box for the telephone number and address for this request.
Right to Receive a Paper Copy of this Notice: You may request a paper copy of this
notice at any time. Please refer to the Contact Information Box for the address
for this request.
Right to Contact Information: You may exercise any of the rights described above
by contacting Group Health Cooperative of Eau Claire. All requests must be made
in writing. Please refer to the Contact Information Box for the telephone number
and address for this request.
TO PRIVACY PRACTICES
This notice may be changed or amended at any time. The changes are effective for
all protected health information that we maintain. Group Health Cooperative of Eau
Claire will redistribute a new Notice of Privacy Practices whenever policy changes
are made.
ADDITIONAL INFORMATION
If you have any questions about this notice or would like an additional copy of
this notice, please refer to the Contact Information Box for the telephone number
and address for this request.
COMPLAINTS
If you are concerned about this Privacy Notice or if you believe that your privacy
rights may have been violated, please forward your written complaint to the address
listed within the Contact Information Box.
You also have the right to file a complaint with the Secretary of the U.S. Department
of Health and Human Services. If you have questions about the complaint process,
please contact us using the information in the Contact Information Box.
You will not lose benefits or eligibility for filing a complaint or a grievance
regarding your privacy rights.
Contact Information Box
For all above indicated requests, please contact Group Health Cooperative of Eau
Claire at
(715) 552-4300 or (888) 203-7770.
Or you may write to the following:
Group Health Cooperative of Eau Claire
Attn: Compliance Privacy Officer
P.O. Box 3217
Eau Claire, WI 54702-3217
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