District Health Plan – HIPAA Notice

Crooksville Exempted Village School District Employee Health Plan

Notice of Privacy Practices Regarding Protected Health Information
Effective Date: April 14, 2004


This Notice of Privacy Practices describe how protected health information may be used or disclosed by your Group Health Plan to carry out payment, healthcare operations and for other purposes that are permitted by law. We’re required to maintain the privacy of your health information and to provide you with this notice. Also, we’re required to abide by the terms of the notice that’s currently in effect. This Notice also describes your rights concerning your health information.

As you read this notice, you’ll see an important term: “protected health information” or PHI. PHI is information about you, including health and demographic information created and received by us that can reasonably be used to identify you. PHI includes information that relates to your past, present, and future physical or mental condition, the provision of health care, and payment for that care.

How We Use or Share Protected Health Information (PHI)

Below are some examples of ways we may use or share information about you without your consent or authorization. These examples are considered to be treatment, payment, and health care operations. We may use or share your PHI:

For payment of healthcare claims and to obtain stop loss reimbursements or otherwise fulfill or responsibilities for coverage and providing benefits. For example, we may disclose your protected health information when a provider requests information regarding your eligibility for coverage under our health plan.
To manage our plan that includes functions such as auditing, monitoring, and managing carve-out plans.
With a third party administrator to handle claim payment and medical management functions.
With organizations (Business Associates) that help us conduct our business operations. We only share your information with businesses that agree to keep it protected.

During the course of our business, there may be additional instances in which your PHI may be used. These instances are described below. We, or our Business Associates may use or share your PHI.

To send you a reminder for important services such as mammograms or prostate cancer screenings.
To give you information about alternative medical treatments and programs or about health-related products and services that may be of interest to you. For example, we might send you information about smoking cessation or weight-loss programs.
With our plan sponsor through which you receive health benefits for the purpose of administering our plan. We have agreed to keep this information protected.

There are state and federal laws that may require or allow us to release your health information to others. We may be required to provide information for the following reasons:

Health Oversight Activities: We may disclose your PHI to a government agency authorized to oversee the health care system or government programs, or its contractors (e.g., state insurance department, U.S. Department of Labor) for activities authorized by law, such as audits, examinations, investigations, inspections and licensure activities.
Legal Proceedings: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances.
Law Enforcement: We may disclose your PHI to law enforcement officials under limited circumstances. For example, in response to a warrant or subpoena, or for the purpose of identifying or locating a suspect, witness, or missing person, or to provide information concerning victims of crimes.
For Public Health Activities: We may disclose your PHI to a government agency that oversees the health care system or government programs for activities such as preventing or controlling disease or activities related to the quality, safety, or effectiveness of an FDA regulated product or activity.
Required by Law: We may disclose your PHI when we’re required to do so by law.
Workers’ Compensation: We may disclose your PHI when required by workers’ compensation laws.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose your PHI to appropriate authorities if we reasonably believe that you’re a possible victim of abuse, neglect, domestic violence or other crimes.
Coroners, Funeral Directors, and Organ Donation: In certain instances, we may disclose your PHI to coroners, or funeral directors, and in connection with organ donation.
Research: We may disclose your PHI to researchers, if certain established steps are taken to protect your privacy.
Threat to Health or Safety: We may disclose your PHI to the extent necessary to avert a serious and imminent threat to your health or safety or the health of safety of others.
For Specialized Government Functions: We may disclose your PHI in certain circumstances or situations to a correctional institution if you are an inmate in a correctional facility, to an authorized federal official when it’s required for lawful intelligence or other national security activities, or to an authorized authority of the Armed Forces.
For Cadaveric Organ, Eye, or Tissue Donation: We may disclose your PHI for the purpose of facilitating organ, eye or tissue donation and transplantation.

Before we can use or disclose your PHI for any reason other than those listed in the section titled, “How We Use of Share Protected Health Information (PHI)”, we are required to obtain your written authorization. You may revoke the authorization at any time as long as you do so in writing. Information provided as a result of your authorization will no longer be provided once you revoke the authorization.

What Are Your Rights

You have the following rights regarding the protected health information (PHI) we maintain about you.

You have the right to ask us to restrict our use and disclosure of protected health information for the purpose of treatment, payment or health care operations. This includes uses and disclosures to family members, relatives, close personal friends, or other persons identified by you who may be involved with your care or payment for your care. We’ll consider your request, but we aren’t required to agree to restrict the information.

You have the right to ask to receive confidential communications. You may request that when we send communications to you that contain PHI, we sent them to you by alternative means or to an alternative location. You must request this in writing and clearly state that our disclosure of all or part of that communication could endanger you. You must also tell us the alternative location (e.g., fax number, address, etc.) to which you would like us to send the information.

You have the right to inspect and obtain a copy of the protected health information (PHI) that we maintain about you in a designated record set. A designated record set contains PHI that we collect, maintain or use to administer or make decisions regarding your enrollment, payment, claims adjudication, or case/medical management. If we don’t maintain the PHI, but we know who does, we’ll tell you. Requests to access the information must be made in writing, and we’ll respond within 30 days of receipt of your request. We may change a reasonable, cost-based fee to provide you with the information. There are exceptions as to what information can be accessed. For example, information compiled for legal proceedings cannot be accessed. If we deny access to your information, in part of whole, we will notify you in writing. Our denial will include the reason for the denial, your review rights (if applicable), and information on how to file a complaint.

You have the right to ask us to amend protected health information about you that’s contained in a designated record set (as described above). All amendment requests must be in writing and include a reason for the request. We’ll respond within 60 days of receiving the request. If the request is approved, we’ll amend the information in our records and notify any other individual(s) whom we know and/or whom you have told us have received the information, and we’ll provide them with the amendment as well. In certain cases, your request may be denied. For example, we may deny a request if the information we have on file is accurate or if we didn’t create the information. We’ll notify you in writing of any denial. You may respond by filing a written statement of disagreement with us, and we have the right to rebut the disagreement statement. Should this occur, you have the right to request that your original request, our denial, and any statement of disagreement, along with our rebuttal, be included in future disclosures of the PHI.

You have the right to request an accounting of certain disclosures of protected health information. An accounting will show you to whom we provided you PHI. The first accounting request in a 12-month period of time will be provided free of charge. Subsequent requests are subject to a reasonable, cost-based fee, of which you will be made aware of in advance. All requests for disclosures must be made in writing, and we’ll respond with 60 days of receipt. There are some accountings we aren’t required to provide. For example, we aren’t required to account for disclosures made for purposes of treatment, payment, or health care operations. Also, we won’t provide accountings for disclosures that you have authorized, and certain other disclosures such as for national security purposes.

You have the right to a paper copy of this notice upon request. You may write us at the address provided in the complaints and inquiries section of this notice, or call us at 740-982-7040 and we’ll mail or fax a current notice to you. This privacy notice is also found on our website at www.crooksville.k12.oh.us. The privacy notice of our Business Associate that administers our plan can be found at www.mmoh.com.

For more information, or to begin the formal process connected with these rights, please contact our Privacy Officer, Michael A. Hankinson, at 740-982-7040.

Complaints and Inquiries

You may register a complaint to us or to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with us, please submit it in writing and address it to:

Crooksville Exempted Village School District
Attn: Michael A. Hankinson, Privacy Officer
4065 School Drive
Crooksville, Ohio 43731

To submit a complaint to the Secretary of Department of Health and Human Services, please submit it in writing to:

Secretary, Department of Health and Human Services
200 Independence Avenue SW
Washington, DC 20201

Your complaint should include the following:

” Your name
” The policyholder’s name
” Contract or policy number
” Name of employer or plan sponsor
” The identification number on the health plan card (this may be the employee’s social security number)
” Address or other means of communicating with you in writing
” A telephone number where you can be reached
” A brief description of the nature of your complaint
” The names and phone numbers, if available, of any of our employees with whom you have discussed your complaint
” Any other information you think is important in order to resolve your complaint

Please note: You won’t be retaliated against or denied any health plan benefit or service because you file a complaint.

Effective Date of This Notice and Revisions to the Notice

This notice is effective April 14, 2004. We’re required to abide by the terms of the notice that’s currently in effect.

We reserve the right to change the terms of this notice and to make the new notice effective for all PHI we maintain. If we change the notice, we will provide it to you by direct mail. Also, it is posted on our website at www.crooksville.k12.oh.us. We will promptly revise and distribute this notice whenever there is a material change to the uses or disclosures, your rights, our duties, or other practices stated in this notice. Except when required by law, a material change to this notice will not be implemented before the effective date of the new notice in which the material change is reflected.