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.
If you have any questions about this notice, please contact the Privacy Officer at 1-800- 303-8120 x5511. E:mail: firstname.lastname@example.org, mail: 9 West Broad Street, Stamford, CT 06902 attention: Ellen Vetrano
In enacting the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Congress mandated the establishment of standards for the privacy of individually identifiable health information. This information, otherwise known as Protected Health Information (PHI), includes demographic, medical and financial information in respect to the health of a specific individual, the provision of health care to such an individual or the payment for the provision of health care to such an individual. This information can be in either oral, written or electronic form.
We are required by law to take reasonable steps to ensure the privacy of any PHI transmitted or maintained by us. We are also required to inform you about our uses and disclosure of Protected Health Information (PHI), your privacy rights with respect to your PHI , your right to file a complaint with us and the Secretary of the U.S. Department of Health and Human Services and the person to contact for further information about our privacy practices.
1. Minimum Necessary Standard
The Privacy Rule requires us to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. The minimum necessary provisions do not apply to the following:
CISI will use and disclose your protected health information primarily for payment or Health Care operations purposes. The definition of each is described below:
Payment – is defined as the various activities of a health plan to obtain premiums, to fulfill their coverage responsibilities and provide benefits under the plan, and to obtain or provide reimbursement for the provision of health care.
These activities may include but are not limited to:
Health Care Operations – defined as certain administrative, financial, legal and quality improvement activities that are necessary to run the business and to support the core functions of treatment and payment. These activities, which are limited to the activities listed in the definition include:
Other purposes for which we are permitted to use or disclose your PHI without your consent or authorization include:
Disclosure of your PHI to the sponsor of your plan: We may be asked by the sponsor of your plan to provide your PHI. If we are asked to do so (your sponsor may want to assess their overall experience with us or monitor us for quality assurance purposes) we may honor such requests to the extent permitted by law.
YOUR HEALTH INFORMATION RIGHTS:
Right of an individual to request restriction of uses and disclosures – You have the right to request restrictions on how your PHI is used and to whom your information is disclosed even if this restriction affects our payment or health care operations. However, we are not required to agree to your requested restriction. You will need to send your request to our office at the address listed on page one to request a restriction.
Right to receive confidential communications - We must accommodate reasonable requests by you to receive communications of protected health information from us by alternative means or at alternative locations, if you clearly state that the disclosure of all or part of that information could endanger you.
Right to inspect and copy protected health information – You have the right to inspect and obtain a copy of your PHI contained in a “designated record set”, for as long as we maintain the PHI. A “designated record set” includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for a health plan; or other information used in whole or in part by or for the covered entity to make decisions about individuals.
Right to access to protected health information – You have the right of access to inspect and obtain a copy of protected health information about you in a designated record set, for as long as the protected health information is maintained in the designated record set, except for:
Right to amend – You have the right to have us amend protected health information or a record about you in a designated record set for as long as the protected health information is maintained in the designated record set.
Right to an accounting of disclosures of protected health information – You have a right to receive an accounting of disclosures of protected health information made by us in the six years prior to the date on which the accounting is requested, except for disclosures:
Right to obtain a paper copy of this notice. If you did not receive this notice in paper form (i.e. you downloaded it from our website) you make request a paper copy at any time. Please contact our office at (800) 303-8120 x5133 to make a request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with us and/or the United States Department of Health and Human Services. We will not retaliate against you for filing such a complaint. To file a complaint with us, please contact our privacy officer, Ellen Vetrano at 800-303-8120 x5511, e:mail at email@example.com, or mail to 9 West Broad Street, Stamford, CT 06902.
Additional Comments: We are required by law to maintain the privacy of protected health information and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this notice which is currently in effect as of April 14, 2003.
We reserve the right to change this notice at any time. We will make the new notice provisions effective for all protected health information that we maintain. We will provide new notices to your plan sponsor for distribution. We will also post a copy in downloadable form on our website at www.culturalinsurance.com.
THE EFFECTIVE DATE OF THIS NOTICE IS April 14, 2003. IT IS APPLICABLE TO PERSONAL HEALTH INFORMATION ABOUT YOU OBTAINED BY US ON OR AFTER April 14, 2003.
CISI representatives are here to assist you.
or call toll-free (800) 303-8120.