AVON-DIXON AGENCY, LLC
FEDERAL HIPAA NOTICE OF PRIVACY
PRACTICES FOR PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
OUR POLICY ON MEDICAL RECORD PRIVACY
This Notice will describe the way our health plan will treat medical records we keep regarding your medical care. We are required to keep records for each of our enrollees of the services you receive, payment for those services, and other information. We are required by law to protect your personal medical record by keeping it private and following certain rules that dictate whether and when we can use or disclose your information.
This notice will inform you of the ways we may use and disclose your health information. It will also notify you of your rights and our obligations in our use and disclosure of your health information.
The law requires us to keep your health information private. We are also required give you this notice and to follow the terms of the notice that is currently in effect. We reserve the right to change this notice and apply those changes to health information we currently have, as well as information we may receive in the future. If we change this notice, you will receive a new copy of this notice within 60 days after the change is made.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
We may use and disclose your health information for a number of purposes in connection with payment for your medical care and in running our health plan. The following lists a number of typical uses and disclosures within our health plan, with explanations to help you understand your rights. You will not be asked to separately authorize us to do these things.
We may use and disclose your health information to health-care providers who treat you for purposes of determining whether and to what extent we are required to pay for health-care services you receive. We may also use or disclose your health information to other health plans, insurance companies, HMOs, or other third parties in order to coordinate benefits or enforce any subrogation rights we may have. For example, we may receive information regarding your diagnosis and treatment in order to pay for your office visits, procedures, x-rays, or laboratory work. We may also provide information to health-care providers to assist them in determining whether we pay for the medical care you are receiving and whether they need to get authorization from us before treating you.
2. Operation Functions
We may use and disclose your health information in the process of running our health plan practice. For example, we may use or disclose your information if we conduct activities to ensure that our enrollees receive quality health coverage. We may also use or disclose your information in training and evaluation of our staff or as part of a review, audit, or legal activities.
3. Disclosure to the Plan Sponsor
We may disclose your health information to your employer to permit your employer to administer the health plan. For example, we may provide health information to your employer to assist it in processing claims, to audit the plan, or to assist in large case management. Your employer may not use your health information it receives from us for employment-related purposes or other benefit plans it maintains. Before we may disclose health information to your employer, we are required to obtain from your employer a written certification that it will use your information only for permitted purposes. Your employer is also required to designate in the plan document for the health plan which of its employees may have access to your health information and to take steps to ensure that access is limited to those employees. We may also provide your employer with summary health information, which has been modified to eliminate personally identifiable information.
4. Treatment Alternatives
We may use and disclose health information to tell you about or recommend treatment alternatives or health-related benefits and services that may be of interest to you.
5. Individuals Involved in Your Care or Payment for Your Care
We may disclose your health information to a family member or friend who is involved in your medical care or who helps pay for your care. We may discuss payment of a claim for benefits with your family or friends, for example, if you are unable to.
6. Required by Law
We will disclose your health information when we are required to do so by federal, state, or local law.
7. Public Health Risks
We may disclose your health information for public health activities, such as reporting disease, injury, or disability; births and deaths; child abuse or neglect; defects, recalls, or problems with drugs, medical devices, or other products; or to prevent or control disease, injury, or disability; and to limit exposure to or risk for diseases or conditions. We may also notify authorities if we believe you have been the victim of abuse, neglect, or domestic violence, if we are required by law to do so, or if you agree to the notification.
8. Health Oversight Activities
We may disclose health information to a health oversight agency authorized by law for audits, investigations, inspections, and licensure. Health oversight agencies generally oversee the health-care system, government health programs (such as Medicare and Medicaid), and the enforcement of civil rights laws.
9. Judicial and Administrative Proceedings
We may disclose your health information in response to a court order or administrative order. We may also disclose your health information to respond to a subpoena, discovery request, or other request that is not issued by a judge or administrator, but only if efforts have been made to inform you of the request or to get a protective order for the information.
10. Law Enforcement
We may release health information if asked to do so by a law enforcement official under the following circumstances:
If you have incurred certain injuries or wounds that are legally required to be reported;
In response to a court order, subpoena, warrant, summons, investigative demand, or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime if under certain limited circumstances;
About a suspicious death that we believe may be the result of criminal conduct;
About criminal conduct on our premises; and
In emergency circumstances to report a crime, its location, or information about the person who may have committed the crime.
11. Coroners, Medical Examiners, and Funeral Directors
We may disclose your health information to a coroner or medical examiner. This may be necessary, for example, to identify or determine the cause of death of a deceased person, or as otherwise required by law. We may also disclose health information to funeral directors as necessary to carry out their duties.
12. Organ and Tissue Donation
We may use or disclose your health information to organizations that handle organ procurement to facilitate organ or tissue donation and transplantation.
13. To Avert a Serious Threat to Health or Safety
We may use and disclose your health information when necessary to prevent or lessen a serious threat to the health and safety of you, the public, or another person. Any disclosure would be made to law enforcement or someone else who can help prevent or lessen the threat.
14. Specialized Government Functions
We may use or disclose your health information for military command authorities, upon your separation or discharge from military service to authorized officials. We may also disclose your health information to the appropriate government officials when it is necessary to conduct intelligence or other national security activities authorized by federal law. In addition, we may release your health information if it relates to protection of the president of the United States or foreign heads of state. Finally, we may disclose certain information related to members of the armed services and foreign military services to the appropriate personnel.
If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official in order to provide you with medical services, protect you or others, or to ensure the safety of the correctional facility.
16. Workers’ Compensation
We may disclose your health information in relation to workers’ compensation or similar program established by law that provides benefits for work-related illness or injuries.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
1. Your Right to Restrict our Activities
You have the right to request that we restrict the use or disclosure of your health information for treatment, payment, or health-care operations (as described above). You may also restrict us from disclosing your health information to family members or friends. For example, you may request that we limit what information we provide to your family members regarding claims being processed for your health care.
We are not required to agree to your request. If we agree to your restrictions or limitations, we will comply with your wishes unless the information is needed to provide emergency treatment to you. To request restrictions or limitations, you must make a written request to the privacy officer identified below. In your written request, you must tell us (1) what information you want to limit; (2) whether you want to limit use of the information and/or disclosure of the information; and (3) to whom the limitations or restrictions will apply (for example, disclosures to your spouse).
2. Your Right to Request Confidential Communications
You have the right to tell us if you would like us to communicate with you using alternative means or at alternative locations, if you tell us that communication by regular means could endanger you. For example, you may ask that we call you at a certain phone number and tell us whether we may leave a message for you.
To request confidential communications, you must make your request in writing to the privacy officer listed below. Your request must specify how or where you wish to be contacted and that communication by regular means could endanger you. We will follow all reasonable requests for confidential communications.
3. Your Right to Inspect and Copy
You have the right to inspect and copy your health information, including most of your medical and billing records. You do not have the right to review any psychotherapy notes, information created for use in legal actions, or other information covered by certain laws.
If you would like to inspect and/or copy your health information, you must submit your request in writing to the privacy officer listed below. If you request a copy of the information, we may charge you a reasonable fee for copying, postage, or other expenses related to your request.
We may deny your request to inspect and/or copy your health information. If we do, you may request that the denial be reviewed. We will choose a licensed health-care professional to review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
4. Your Right to Amend
If you feel your health information is incorrect or incomplete, you may ask us to amend your records. To request an amendment, you must submit a written request to the privacy officer identified below. Your request must state the reason you believe an amendment is necessary.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if: (a) we did not create the information (unless the entity that created the information is no longer available); (b) the information is not in our possession or control; (c) you would not be permitted to inspect or copy the information; or (d) the information is accurate and complete.
5. Your Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures.” This is a list of certain disclosures of your health information.
To request this list of disclosures, you must submit a written request to the privacy officer identified below. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003 [2004 for small health plans]. You will receive one list per year without charge. We may charge you for the costs of providing additional lists within a year after your first request. We will notify you of the cost involved, and you may choose to withdraw or modify your request if you do not wish to pay the cost.
6. Your Right to Receive a Paper Copy of this Notice
If you are receiving this notice electronically, you have the right to request a paper copy of this notice by making a request to the privacy officer identified below.
CHANGES TO THIS NOTICE
We reserve the right to change this notice, and to apply the revisions or changes notice to health information we already have about you, in addition to information we create or receive in the future.
If you believe your privacy rights have been violated, you may file a complaint with the privacy officer identified below or with the United States Secretary of the Department of Health and Human Services. To file a complaint with our medical practice, contact the privacy officer at the phone number or address listed below to file a written complaint. We encourage your feedback regarding our privacy policies, and we will not retaliate against you in any way if you file a complaint.
OTHER USES OF YOUR HEALTH INFORMATION
This notice only describes the ways we may use and disclose your health information without obtaining further permission from you. There may be other reasons we may request to use or disclose your health information. If we need to do so, we are required to get your written authorization. If you grant us this further authorization, you may revoke it at any time by giving us written notice that you no longer authorize us to use or disclose your health information for those purposes. Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the services that we provided to you.
For questions regarding this notice, or to receive further information, please contact:
The Avon-Dixon Agency, LLC
28640 Marys Ct.