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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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