PRIVACY NOTICE
This notice is in effect as of 04-14-04. 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.
1.Statement of Our Duties
We are required by law to maintain
the privacy of your personal health information and to provide you with this
notice of our privacy practices and legal duties. We are required to abide by
the terms of this notice. We reserve the right to change the terms of this
notice and to make any new provisions effective to all of the personal health
information that we maintain about you. If we revise this notice, we will
provide you with a revised notice by mail.
2.Statement of Your Rights
You have a right to know how we
may use or disclose you personal health information. This notice informs you of
those uses and disclosures. There are certain uses and disclosures of your
personal health information that we are permitted or required to make by law
without your permission. For all other uses and disclosures, we first must
obtain your permission. In addition, you have the following rights:
The right to request that we place additional restrictions on our uses and
disclosures of your personal health information. However, we are not obligated
to agree to impose any such additional restrictions.
The right to access, inspect and copy the protected information pertaining to
you that we maintain in our files about you, and the right to have us correct or
amend any information that we create in error. Requests to access or amend your
health information should be sent to the contact person and address provided in
paragraph 6.
The right to receive an accounting of the disclosures of your personal health
information that we make for purposes other than activities related to your
treatment, or our payment functions or other health care operations.
The right to request that you receive communications of personal health
information in a confidential manner.
3.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.
4. Permissible Uses and Disclosures of Protected Information
To Carry Out Treatment Functions. We may use or disclose your health information
without
your permission for health care providers to provide you with
treatment.
To Carry Out Payment Functions. 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 and conducting quality assessment activities.
In Situations Permitted Or Required By Law. We also may use or disclose your
protected health information without your written permission for other purposes
permitted or required by law, including the following: None.
Exception: To a law enforcement official for law enforcement purposes or in
response to a court order in the course of any judicial or administrative
proceeding.
For Any Purposes To Which You Have Not Objected. In certain limited
circumstances, we may use or disclose your protected health information after we
have given you an opportunity to object and you have not objected. For example,
if you do not object, we may use limited information about you to maintain an
office directory, to notify family members or any other person identified by you
regarding issues directly related to such person's involvement with your care or
payment for that care, or in emergency circumstances.
For Purposes For Which We Have Obtained Your Written Permission. All other
uses or disclosures of your protected health information will be mad only with
your written permission, and any permission that you give us may be revoked by
you at any time.
5. Complaints About Misuse of Health Information
You may complain either directly to us or to the Secretary of Health and
Human Services if you believe that you rights with respect to our protection of
your health information have been violated. To file a complaint with us, you may
submit a complaint in writing that includes as many details (such as names and
dates) as possible. You will not be retaliated against in any way for filing a
complaint.
6. Our Practices 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.
7. Our Policy Regarding Dispute Resolution
Any controversy or
claim arising out of or relating to our privacy policy, or the breach thereof,
shall be settled by arbitration in accordance with the rules of the American
Arbitration Association, and judgment upon the award rendered by the
arbitrator(s) may be entered in any court having jurisdiction thereof.
8. Contact Person For Filing Complaint or Obtaining Further
Information
Joseph D Fischer, President
231-533-6161
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