Effective Date: April 14, 2004 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. INTRODUCTION 1. Make sure that protected health information is kept private; 2. Give you this notice of our legal duties and privacy practices with respect to protected health information about you; and 3. Follow the terms of the notice that is currently in effect. • This notice will tell you about the ways in which the Plan, Plan Sponsor and their respective agents may use and disclose protected health information about you without authorization. These persons and entities may share medical information with each other for treatment, payment or health care operations purposes as described in this notice. This notice also describes your rights and certain obligations the Plan and the Plan Sponsor have regarding the use and disclosure of your medical information. The term „Protected Health Information‰ means any individually identifiable health information relating to the physical or mental health or condition of an individual, the provision of health care to an individual, or payment for the provision of health care to an individual. Protected Health Information does not include health information that has been de-identified in accordance with the standards for de-identification provided for in the HIPAA Privacy Rule. CHANGES TO THIS NOTICE HOW THE PLAN MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU 1. Treatment means the provision, coordination or management of your health care, including referrals for health care from one health care provider to another. For example, a provider may need to know health care information in Plan files that might assist in your treatment. 2. Payment means activities relating to reimbursement for the health care provided to you, including eligibility and benefit determination and other utilization review activities. This would also include other benefit plans to which you are entitled to payment for some or all of your health care services so that the Plan can coordinate its benefits with those plans. For example, the Plan may need information about your medical condition to determine if a proposed course of treatment is covered. 3. Health Care Operations means administrative functions necessary to operate the Plan. These functions include but are not limited to quality assurance activities, case management, claim audits and reviews and business planning. For example, the Plan may use your medical information to evaluate the Plan‚s performance and to determine how to best provide benefits under the Plan. 4. To Provide Limited Information to the Plan Sponsor. The Plan may share information about you with the Plan Sponsor (in this case, the corporate management of The Apple Gold Group). In the vast majority of circumstances, the Plan shares only summary information with the Plan Sponsor about the types and frequency of claims, the total cost for those claims, and other related information that does not identify any particular beneficiary. This summary information is used for the purposes of determining levels of excess insurance or reinsurance the Plan Sponsor should purchase, setting or adjusting levels of contributions required of participants to become or remain eligible to participate in the Plan, making decisions on amendments or modifications to the Plan, and making decisions whether to continue the Plan. The Plan does not need your permission to share this information with the Plan Sponsor. • The Plan retains an administrator to assist it in administering the claims processing, claim review, and claim payment functions conducted by the Plan. As a result, the administrator will receive the majority of health information involving you and your health benefit claims and has agreed to be bound by the same restrictions as the Plan in its use and disclosure of your health information. • In some cases, however, The Plan Sponsor may receive specific information about particular Plan participants. For example, reinsurers and other benefit providers may need information on certain chronic or catastrophic illnesses and injuries in order to quote premiums or to continue coverage under some or all of the Plan Sponsor‚s insurance policies, including those that insure a portion of the Plan. In these cases, the following rules will apply: 1. The Plan Sponsor will not use this information in a way that violates HIPAA. 2. The Plan Sponsor will ensure that any third parties who receive this information (such as the administrator, insurance brokers, benefits consultants, and the like) agree to the same restrictions on the use of this information as those required of the Plan Sponsor. 5. The Plan Sponsor will discipline any employee or partner that violates the Plan‚s provisions regarding health information privacy or the other requirements of HIPAA. 6. The Plan Sponsor will, if feasible, return to the Plan or destroy this information once it is no longer needed for the purposes for which it was obtained. If it is not feasible to return or destroy this information, the Plan Sponsor will limit the use of the information to those purposes that make return or destruction not feasible. • You may also request that Plan Sponsor employees intervene on your behalf in addressing claims payment issues or to resolve coverage questions under the Plan (such as, for example, whether a particular requested service is experimental or medically necessary). Should you make such a request, you will be deemed to have consented to the Plan sharing all of the information about your medical condition or your claim with the Plan Sponsor. The Plan Sponsor will use and disclose this information only in accordance with the restrictions outlined above. 1. Health-Related Benefits and Services. The Plan may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. 2. Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. This would include persons named in any durable health care power of attorney or similar document provided to us. We may also give information to someone who helps pay for some or all of your care. If you are not present or cannot agree or object, we will use our professional judgment to decide whether it is in your best interest to release relevant information to someone who is involved in your care. 3. As Required By Law. The Plan will disclose medical information about you when required to do so by federal, state, or local law. 4. To Avert a Serious Threat to Health or Safety. The Plan may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. SPECIAL SITUATIONS - The plan and/or Plan Sponsor may also use or disclose your medical information in the following situations without your authorization. 1. Organ and Tissue Donation. If you are an organ donor, the Plan may release medical information to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation. 2. Military and Veterans. If you are a member of the armed forces, the Plan may release medical information about you as required by military command authorities. The Plan may also release medical information about foreign military personnel to the appropriate foreign military authority. The Plan may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits. 3. Public Health Risks. The Plan may disclose medical information about you for public health activities. These activities generally include the following: • To prevent or control disease, injury, or disability; • To report deaths; • To report reactions to medications or problems with products; to notify people of recalls of products they may be using; • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and • To notify the appropriate government authority if the Plan believes a Plan participant has been the victim of abuse, neglect, or domestic violence. The Plan will only make this disclosure if you agree or when required or authorized by law. 1. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, the Plan may disclose medical information about you in response to a court or administrative order. The Plan may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 2. Law Enforcement. The Plan may release medical information if asked to do so by a law enforcement official: • In response to a court order, subpoena, warrant, summons, 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, the Plan is unable to obtain the person‚s agreement; • About a death the Plan believes may be the result of criminal conduct; • About criminal conduct at the Plan Sponsor‚s workplace; and • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime. 1. Coroners and Medical Examiners. The Plan may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. 2. National Security and Intelligence Activities. The Plan may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. 3. Protective Services for the President and Others. The Plan may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION • To inspect and copy medical information, you must submit your request in writing to the Plan‚s Privacy Officer. If you request a copy of the information, the Plan may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If you agree, the Plan may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, the Plan first will obtain your agreement to pay the fees, if any, for preparing the summary or explanation. • We may deny your request to inspect and copy your medical information in certain very limited circumstances, such as when your physician determines that for medical reasons this is not advisable. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the Plan will review your request and the denial. The person conducting the review will not be the person who denied your request. The Plan will do what this person decides. 1. Right to Amend. You have the right to request corrections or amendments to your health information. Such corrections will not replace existing records but will be included as additions to these records. 2. Right to an Accounting of Disclosures. You have the right to request an „accounting of disclosures.‰ This is a list of some of the disclosures the Plan made of medical information about you that were not specifically authorized by you in advance. • To request this list or accounting of disclosures, you must submit your request in writing to the Plan‚s Privacy Officer. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, the Plan may charge you for the costs of providing the list. The Plan will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. 1. Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information the Plan uses or discloses about you for purposes of treatment, payment or operations. To request restrictions, you must make your request in writing to the Plan's Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply. • We are not required to agree to your request. If the Plan does agree, the Plan will comply with your request. 1. Right to Confidential Communications. You have the right to request to receive communications from us on a confidential basis by using alternative means for receipt of information or by receiving the information at alternative locations. For example, you can ask that the Plan only contact you at work or by mail, or at another mailing address, besides your home address. The Plan must accommodate your request, if it is reasonable. You are not required to provide us with an explanation as to the reason for your request. Contact the Plan‚s Privacy Officer if you require such confidential communications. 2. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. • To obtain a paper copy of this notice, request a copy from the Plan‚s Privacy Officer in writing. COMPLAINTS You will not be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION CONTACT PERSON |