Privacy/Terms of Use
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
