Notice of Privacy PracticesTHIS 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.This notice of Privacy Practices is directed to all members of AvMed’s health plans. It 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 or mental health condition, the provision of health care to you or the payment for that care. We are required to maintain the privacy of your protected health information and to provide you this notice about our legal duties and privacy practices. We must follow the privacy practices described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace or modify it. 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 for 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. For some plans, we may also use and disclose protected health information for purposes of obtaining premiums, underwriting, ratemaking, and determining cost sharing amounts. Health Care Operations: We will use and disclose your protected health information to support other business activities, including the following:
In connection with the foregoing activities, we may collect the following types of information about you:
We may, in the case of some group health plans, disclose protected health information to the plan sponsor (e.g., your employer) to permit the plan sponsor to perform plan administration functions. Please see your plan documents, where applicable, for a full explanation of the limited uses and disclosures that the plan sponsor may make of your protected health information in providing plan administration 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 that information against inappropriate use and disclosure apply regardless of the status of any individual 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 the federal standards. Other Uses and Disclosures We may also use or disclose your protected health information in the following situations without your consent or authorization. Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person 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 (whether in person or on a telephone call), 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. For example, if a family member or a caregiver calls our customer service line with basic information about you (address, date of birth, etc.) and with prior knowledge of a claim, we will confirm whether or not the claim has been received and paid, unless you have previously informed us in writing that you do not want us to make any such disclosures to that party. 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 explanation of benefits forms and other mailings containing protected health information to the address we have on record for the subscriber of the health benefits plan. We will not make separate mailings for enrolled dependents of the subscriber, unless it is requested in writing. Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request, or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. Seq. Uses and Disclosures Based Upon Your Written Authorization We require a special written authorization before making any disclosure of personal information for purposes not listed above (e.g., marketing/promotional activities and research projects conducted by third parties, etc.). In the event that you are unable to give the required consent (for example, if you are or become legally incompetent), we accept consent from any person legally authorized to give consent on your behalf. A special authorization may be revoked except to the extent that we have taken action upon it. To revoke a special authorization that you previously gave, you may send us a letter stating that you would like to revoke your special authorization. Please provide your name, address, member identification number, the date the special authorization was given, and a telephone number where you may be reached. Your Rights Regarding Medical and Health Information About You Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to AvMed. In your request, you must tell us (a) what information you want to limit; (b) whether you want to limit our use, disclosure or both; and (c) to whom you want the limits to apply. Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location, if you advise us that communicating with you in the usual manner could endanger you. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to AvMed, stating that communicating with you in the usual manner could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to Inspect and Copy: You have the right to inspect and receive copies of medical information that may be used to make decisions about your care. Usually, this includes enrollment, payment, claims adjudication, and case or medical management record systems maintained by AvMed. If you want to access the claims or other related information we maintain concerning you and your dependents, or the identity, if recorded, of those persons to whom personal information has been disclosed, you must submit your request in writing to AvMed Health Plans. Records will be available for transactions that occur after April 14, 2003. We may charge a fee for the costs of copying, mailing, or other administrative expenses associated with your request. If you want to access medical record information about yourself, or if you have a question regarding your care, you should go to the provider (e.g. doctor, pharmacy, hospital or other caregiver) that generated the original records. We do not have custody of these medical records. If you believe the information in your medical records is wrong or incomplete, contact the provider who was responsible for the service or treatment in question. If we are the source of a confirmed error in our records concerning you, we will correct or amend the records we maintain. We are not able to correct the records created or maintained by your provider or other third parties. Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for AvMed. To request an amendment, your request must be made in writing and submitted to AvMed Health Plans. In addition, you must provide a reason that supports your request. 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 you ask us to amend information that:
This page's verbiage (but not its layout) last modified February 15, 2007 |
