NOTICE OF PRIVACY PRACTICES
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.
Association & Society Insurance Corp. (ASI) is committed to protecting the privacy of your health information. ASI is required by a federal law, the Health Insurance Portability and Accountability Act (HIPAA), to take reasonable steps to ensure the privacy of your “Protected Health Information” (PHI) and to provide you with this Notice of Privacy Practices. This Notice applies to Tricare/CHAMPUS coverage only.
The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by ASI and/or its business associates regardless of form (oral, written, electronic).
Effective Date: This Notice is effective April 14, 2003.
If you have any questions about this Notice, or the subjects addressed in it, please call Lanny Evans, HIPAA Specialist. 1-800-638-2610, Ext. 124.
Uses and Disclosures of Your PHI
This section of the Notice explains how ASI uses and discloses your PHI with our employees, our business associates and other organizations as required or permitted by law without your authorization. We also require our business associates to protect the privacy of your PHI through written agreements with ASI. As explained below, in some instances we will request your written authorization to use or disclose PHI.
Required Disclosures. Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate and/or determine ASI’s compliance with HIPAA’s privacy regulations.
Uses and Disclosures Related to Treatment, Payment and Healthcare Operations. ASI and/or its business associates may use and disclose PHI without your authorization or opportunity to agree or object for activities related to treatment, payment and healthcare operations. In these instances, ASI will not request your authorization to share PHI. As described in the next section titled Your Privacy Rights , you have the right to request a restriction on the use and disclosure of your PHI for treatment, payment or healthcare operations purposes.
Examples of activities related to payment include: payment of healthcare claims, determinations whether a member is eligible for healthcare coverage, or collection of premiums.
Examples of activities related to healthcare operations include: quality improvement, fraud and abuse prevention and detection, case management and medical review, and complaint resolution.
Uses and Disclosures of Your PHI That Do Not Require Your Authorization or Opportunity to Object. Your PHI may be disclosed without your authorization in the following circumstances: when required by law; for public health activities; about victims of abuse, neglect, or domestic violence; for governmental health oversight activities (including audits, investigations, and inspections); for judicial and administrative proceedings; for certain law enforcement purposes; about deceased persons to coroners, health examiners, and funeral directors; for organ and tissue donation; for certain government-approved research purposes; upon reasonable belief to avert a serious threat to health or safety; for specialized government functions (such as military personnel, and inmates in correctional facilities); or for workers’ compensation.
Use and Disclosures to Plan Sponsor. ASI may also disclose PHI to the sponsor of your group health plan for plan administration functions.
Use and Disclosure to Contact You Regarding Health-Related Benefits and Services. ASI or its business associates may also contact you regarding health-related benefits and services that may be of interest to you.
Uses and Disclosures That Require Your Written Authorization. In all other circumstances, uses and disclosures of your PHI will only be made with your written authorization. You may revoke such an authorization at any time, except to the extent ASI, or its business associates or other entities have relied on such disclosure.
Your Privacy Rights
This section of the Notice describes your rights as an individual with respect to your PHI and a brief description of how you may exercise these rights.
Right to Restrict Uses and Disclosures for Treatment, Payment and Healthcare Operations Purposes. You have the right to request that we restrict uses and disclosure of your PHI for activities related to treatment, payment and healthcare operations as described above. Your request for the restriction must be in writing. We will evaluate all requests for restrictions, however, we are not required to agree to the restriction. If we agree to the restriction, we will abide by it except as in the case of emergency treatment or required by law. We will terminate our agreement to a restriction if you agree to or request the termination of the restriction. If we decide to terminate our agreement to the restriction, we will notify you of our decision.
Right to Request Confidential Communications. You may request that we communicate with you by alternative means or at alternative locations. For example, you may wish to receive communications from us at your work location rather than your home. We will evaluate all such requests, however we must only accommodate your request if you clearly state that the communication of all or part of your PHI could endanger you.
Right to Inspect and Copy Your PHI. You have a right to access, inspect and copy your PHI contained in a “designated record set” for as long as ASI maintains the PHI in the designated record set. However, you do not have an automatic right to access psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a criminal, civil or administrative action or proceeding. We will act on a request for access within 30 days of receiving your request if the information is maintained and accessible on site or within 60 days otherwise (with a possible 30-day extension). We will provide you with a summary of the PHI requested if you agree in advance to the summary and to the fees imposed.
We may deny your request to access your PHI under certain circumstances . If your request is denied, we will send you a notice that explains our reason for the denial, your review rights, if any, and how to file a complaint with our Privacy Official or the Secretary of the Department of Health and Human Services.
If your request for access is denied, in certain instances we will provide you with an opportunity for a review of the denial. The review decision must be made in a reasonable period of time, and we will provide you with a written notice of the review decision.
We may charge a reasonable fee for access, inspection and/or copying of your PHI. This fee is based on the costs associated with copying, mailing and summary preparation costs.
Right to Amend Your PHI. You have the right to request that we amend your PHI if you believe the information is incorrect or inaccurate. We may deny your request to amend your PHI, if we did not create the PHI, if the information is not part of our records, if the information was not available for inspection, or if the information is accurate and complete. We will respond to your written request to amend your PHI within 60 days of the request (with a possible 30-day extension).
If your request for amendment is granted, we will notify you that the amendment was approved and obtain your identification of and agreement to inform relevant persons. We will make reasonable efforts to inform and provide the amendment within a reasonable time to persons identified by you and by us, including our business associates.
If your request for the amendment is denied, we will send you a written notice that explains the reason for the denial, your right to submit a written statement of disagreement or to have the request for amendment included with future disclosures, and your right to file a complaint with our Privacy Official and/or the Secretary of the Department of Health and Human Services.
We may prepare a rebuttal statement to your statement of disagreement. We will provide you with a copy of the rebuttal statement.
Any future disclosures of your PHI will include the statement of disagreement or request for amendment, the denial notice, and the rebuttal or summary of this information.
Right to an Accounting of Disclosures. You have the right to receive an accounting of disclosures of your PHI made by ASI during the six years prior to the date of your request. We will act on your request for an accounting of disclosures within 60 days (with a possible 30-day extension).
This accounting of disclosures will not include disclosures made:
prior to effective date of HIPAA, April 14, 2003;
We will provide you with one free accounting each year. For subsequent requests, we will charge a reasonable fee.
The written accounting of disclosures will include the following information for each disclosure: the date of the disclosure, the person to whom the informationwas disclosed, a brief description of the information disclosed or in lieu of the summary, a copy of the written request for the disclosure.
Right to a Copy of Notice of Privacy Practices. You have the right to receive a paper copy of this Notice upon request, even if you agreed to receive the Notice electronically.
Complaints. You may file a complaint to ASI or the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with ASI, contact Lanny Evans, HIPAA Specialist. 1-800-638-2610, Ext. 124. We will not retaliate against you for filing a complaint.
ASI’s Duties
ASI will abide by the terms of this Notice of Privacy Practices.
ASI reserves the right to change its privacy practices and apply the changes to any PHI received or maintained by ASI prior to that date. If a privacy practice is materially changed, ASI will provide you with a revised Notice of Privacy Practices.
Document Number: NOT-013-330 Date: January 22, 2003 Version: 1.0
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