NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH 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 describes how protected health information (or “PHI”) may be used or disclosed by your Group Health Plan to carry out payment, health care operations, and for other purposes that are permitted or required by law. This Notice of Privacy Practices also explains your Group Health Plan’s legal obligations
concerning your PHI, and describes your rights to access, amend and manage your PHI.

PHI is individually identifiable health information, including demographic information, collected from you or created and received by a health care provider, a health plan, your employer (when functioning on behalf of the group health plan), or a health care clearinghouse and that relates to: (i) your past, present or future physical or mental health or condition; (ii) the provision of health care to you; or (iii) the past, present, or future payment for the provision of health care to you.

This Notice of Privacy Practices has been drafted to be consistent with the HIPAA Privacy Rule. Any terms not defined in this Notice have the same meaning as they have in the HIPAA Privacy Rule. If you have any questions about this Notice or the policies and procedures described herein, please contact:

THE PLAN’S RESPONSIBILITIES

The Plan is required by law to maintain the privacy of your PHI. The Plan is obligated to: provide you with a copy of this Notice of the Plan’s legal duties and of its privacy practices related to your PHI; abide by the terms of the Notice that is currently in effect; and notify you in the event of a breach of your unsecured PHI. The Plan reserves the right to change the provisions of its Notice and make the new provisions effective for all PHI that the Plan maintains. If the Plan makes a material change to this Notice, the Plan will make the revised Notice available to
you by means of a legally compliant delivery method.

Permissible Uses and Disclosures of PHI

The following is a description of how the Plan is most likely to use and/or disclose your PHI.

Payment and Health Care Operations
The Plan has the right to use and disclose your PHI for all activities that are included within the definitions of “payment” and “health care operations” as set out in 45 CFR § 164.501 (this provision is a part of the HIPAA Privacy Rule). Not all of the activities listed in this Notice are included within these definitions. Please refer to 45 CFR § 164.501 for a complete list. In order to administer your health benefits, the Plan may use or disclose your health information in various ways without your authorization, including:

Payment
The Plan will use or disclose your PHI to pay claims for services provided to you and to obtain stop-loss reimbursements or to otherwise fulfill its responsibilities for coverage and providing benefits. For example, the Plan may disclose your PHI when a provider requests information regarding your eligibility for coverage under the Plan, or the Plan may use your information to determine if a treatment that you received was medically necessary.

Health Care Operations
The Plan will use or disclose your PHI to support its business functions. These functions include, but are not limited to: quality assessment and improvement, reviewing provider performance, licensing, stop-loss underwriting, business planning, and business development. For example, the Plan may use or disclose your PHI: (i) to provide you with information about a disease management program; to respond to a customer service inquiry from you; or (ii) in connection with fraud and abuse detection and compliance programs. The PHI used or disclosed for these operational activities is limited to the minimum amount that is reasonably necessary to complete these tasks.

Other Permissible Uses and Disclosures of PHI

The following describes other possible ways in which the Plan may (and is permitted to) use and/or disclose your PHI.

  • Required by Law
    The Plan may use or disclose your PHI to the extent the law requires the use or disclosure. When used in this Notice, “required by law” is defined as it is in the HIPAA Privacy Rule. For example, the Plan may disclose your PHI when required by national security laws or public health disclosure laws.
  • Public Health Activities
    The Plan may use or disclose your PHI for public health activities that are permitted or required by law. For example, the Plan may use or disclose information for purpose of preventing or controlling disease, injury or disability, or the Plan may disclose such information to a public health authority authorized to receive reports of child abuse or neglect. The Plan also may disclose PHI, if directed by a public health authority, to a foreign government agency that is collaborating with the public health authority. 
  • Health Oversight Activities
    The Plan may disclose your PHI to a health oversight agency for activities authorized by law, such as: audits: investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies seeking this information include government agencies that oversee: (i) the health care system; (ii) government benefit programs; other government regulatory programs; and (iv) compliance with civil rights laws.
  • Abuse or Neglect
    The Plan may disclose your PHI to a government authority that is authorized by law to receive reports of abuse, neglect or domestic violence. Additionally, as required by law, the Plan may disclose to a governmental entity authorized to receive such information, your PHI, if the Plan believes that you have been a victim of abuse, neglect, or domestic violence.
  • Legal Proceedings
    The Plan may disclose your PHI: (i) in the course of any judicial or administrative proceeding: (ii) in response to an order of a court or an administrative tribunal (to the extent such disclosure is expressly authorized); and (iii) in response to a subpoena, a discovery request, or other lawful process, once all administrative requirements of the HIPAA Privacy Rule have been met. For example, the Plan may disclose your PHI in response to a subpoena for such information but only after certain conditions of theHIPAA Privacy Rule are complied with.
  • Law Enforcement
    Under certain conditions, the Plan may also disclose your PHI to law enforcement officials. Some of the reasons for such a disclosure, for example, may include, but not be limited to: (i) it is required by law; (ii) it is necessary to locate or identify a suspect, fugitive, material witness, or missing person; and (iii) it is necessary to provide evidence of a crime that occurred on the Plan’s premises.
  • Coroners, Medical Examiners, Funeral Directors, Organ Donation Organizations
    The Plan may disclose PHI to a coroner or medical examiner for purposes of identifying a deceased person, determining a cause of death, or for the coroner or medical examiner to perform other duties authorized by law. The Plan also may disclose, as authorized by law, information to funeral directors so that they may carry out their duties. Further, the Plan may disclose PHI to organizations that handle organ, eye, or tissue donation and transplantation.
  • Research
    The Plan may disclose your PHI to researchers when an institutional review board or privacy board has: (i) reviewed the research proposal and established protocols to ensure the privacy of the information; and (ii) approved the research.
  • To Prevent a Serious Threat to Health or Safety
    Consistent with applicable federal and state laws, the Plan may disclose your PHI if the Plan believes that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. The Plan may also disclose PHI if it is necessary for law enforcement to identify or apprehend an individual.
  • Research
    The Plan may disclose your PHI to researchers when an institutional review board or privacy board has: (i) reviewed the research proposal and established protocols to ensure the privacy of the information; and (ii) approved the research.
  • Military Activity and National Security, Protective Services
    Under certain conditions, the Plan may disclose your PHI if you are, or were, Armed Forces personnel for activities deemed necessary by appropriate military command authorities. If you are a member of foreign military service, the Plan may disclose, in certain circumstances, your information to the foreign military authority.
  • Inmates
    If you are an inmate of a correctional institution, the Plan may disclose your PHI to the correctional institution or to a law enforcement official for: (i) the institution to provide health care to you; (ii) your health and safety and the health and safety of others; or (iii) the safety and security of the correctional institution.
  • Workers’ Compensation
    The Plan may disclose your PHI to comply with workers’ compensation laws and other similar programs that provide benefits for work-related injuries or illnesses.
  • Emergency Situations
    The Plan may disclose your PHI in an emergency situation, or if you are incapacitated or not present, to a family member, close personal friend, authorized disaster relief agency, or any other person previously identified by you. The Plan will use professional judgment and experience to determine if the disclosure is in your best interests. If the disclosure is in your best interest, the Plan will disclose only the PHI that is directly relevant to the person’s involvement in your case.
  • Fundraising Activities
    The Plan may use or disclose your PHI for fundraising activities, such as raising money for a charitable foundation or similar entity to help finance its activities. If the Plan contacts you for fundraising activities, the Plan will give you the opportunity to opt-out or stop receiving such communications in the future.
  • Group Health Plan Disclosures
    The Plan may disclose your PHI to a sponsor of the group health plan – such as an employer or other entity – that is providing a health care program to you. The Plan can disclose your PHI to that entity if that entity has contracted with us to administer your health care program on its behalf.
  • Underwriting Purposes
    The Plan may use or disclose your PHI for underwriting purposes, such as to make a determination about a coverage application or request. If the Plan does use or disclose your PHI for underwriting purposes, the Plan is prohibited from using or disclosing in the underwriting process your PHI that is genetic information.
  • Others Involved in Your Health Care
    Using its best judgment, the Plan may make your PHI known to a family member, other relative, close personal friend or other personal representative that you identify. Such a use will be based on how involved the person is in your care, or payment that relates to your care. The Plan may release information to parents or guardians if allowed by law.
     
    If you are not present or able to agree to these disclosures of your PHI the Plan, using its professional judgment, may determine whether the disclosure is in your best interest.

Uses and Disclosures of Your PHI that Require Your Authorization

Sale of PHI
The Plan will request your written authorization before it makes any disclosure that is deemed a sale of your PHI, meaning that the Plan is receiving compensation for disclosing the PHI in this manner.

Marketing
The Plan will request your written authorization to use or disclose your PHI for marketing purposes with limited exceptions, such as when the Plan has face-to–face marketing communications with you or when the Plan provides promotional gifts of nominal value.

Psychotherapy Notes
The Plan will request your written authorization to use or disclose any of your psychotherapy notes that the Plan may have on file with limited exception, such as for certain treatment, payment or health care operation functions.

Other uses and disclosures of your PHI that are not described above will be made only with your written authorization. If you provide the Plan with such an authorization, you may revoke the authorization in writing and this revocation will be effective for future uses and disclosures of PHI. However, the revocation will not be effective for information the Plan has already used or disclosed, relying on the authorization.

Required Disclosures of Your PHI

The following describes disclosures that the Plan is required by law to make.

  • Disclosures to the Secretary of the U.S. Department of Health and Human Services
    The Plan is required to disclose your PHI to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining the Plan’s compliance with the HIPAA Privacy Rule.
  • Disclosures to You
    The Plan is required to disclose to you most of your PHI in a “designated record set” when you request access to this information. Generally, a “designated record set” contains medical and billing records as well as other records that are used to make decisions about your health care benefits. The Plan also is required to provide, upon your request, an accounting of most disclosures of your PHI that are for reasons other than payment and health care operations and are not disclosed through a signed authorization.
     
    The Plan will disclose your PHI to an individual who has been designated by you as your personal representative and who has qualified for such designation in accordance with applicable state law. However, before the Plan will disclose PHI to such a person, you must submit a written notice of his/her designation, along with the documentation that supports his/her qualification (such as a power of attorney).

Even if you designate a personal representative, the HIPAA Privacy Rule permits the Plan to elect not to treat the person as your personal representative if the Plan has a reasonable belief that: (i) you have been, or may be, subjected to domestic violence, abuse or neglect by such person; (ii) treating such person as your personal representative could endanger you; or (iii) the Plan determines, in the exercise of its professional judgment, that it is not in your best interest to treat the person as your personal representative.

  • Business Associates
    The Plan contracts with individuals and entities (Business Associates) to perform various functions on its behalf or to provide certain types of services. To perform these functions or to provide the services, the Business Associates will receive, create, maintain, use or disclose PHI, but only after the Business Associate agrees in writing to contract terms designed to appropriately safeguard your information. For example, the Plan may disclose your PHI to a Business Associate to administer claims or to provide member service support, utilization management, subrogation, or pharmacy benefit management.
  • Other Covered Entities
    The Plan may use or disclose your PHI to assist health care providers in connection with their treatment or payment activities, or to assist other covered entities in connection with payment activities and certain health care operations. For example, the Plan may disclose your PHI to a health care provider when needed by the provider to render treatment to you, and it may disclose PHI to another covered entity to conduct health care operations in the areas of quality assurance and improvement activities, or accreditation, certification, licensing or credentialing. This also means that the Plan may disclose or share your PHI with insurance carriers in order to coordinate benefits if you or your family members have coverage through another carrier.
  • Plan Sponsor
    The Plan may disclose your PHI to the plan sponsor of the Group Health Plan for purposes of plan administration or pursuant to an authorization request signed by you. Additional Protections for Certain Categories of PHI – Certain types of Protected Health Information (PHI) may be subject to enhanced privacy protections under federal and/or state laws. These additional protections may apply to:
    • Psychotherapy notes
    • PHI related to reproductive health care
    • PHI concerning alcohol and drug abuse prevention, treatment, and referral
    • PHI involving HIV/AIDS testing, diagnosis, or treatment
    • PHI related to venereal and other communicable diseases
    • PHI associated with genetic testing

  • Additional Privacy for Substance Use Disorder (SUD) Treatment – The Plan may receive information from a substance use disorder treatment program (“SUD Program”), about your treatment. The Plan will not disclose this information so that it can be used in a civil, criminal, administrative, or legislative proceeding against you unless (i) we have your written consent, or (ii) a court order accompanied by a subpoena or other legal requirement compelling disclosure issued after we and you were given notice and an opportunity to be heard.
     
    Redisclosure – Understand that once your PHI is disclosed it may be no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA) and may be subject to re-disclosure.

Potential Impact of State Law

The HIPAA Privacy Rule regulations generally do not “preempt” (or take precedence over) state privacy or other applicable laws that provide individuals greater privacy protections. As a result, to the extent state law applies, the privacy laws of a particular state, or other federal laws, rather than the HIPAA Privacy Rule regulations, might impose a privacy standard under which the Plan will be required to operate. For example, where such laws have been enacted, the Plan will follow more stringent state privacy laws that relate to uses and disclosures of PHI concerning HIV or AIDS, mental health, substance abuse/chemical dependency, genetic testing, reproductive rights, etc. 

YOUR RIGHTS

  • Right to Request Restrictions
    You have the right to request a restriction on the PHI the Plan uses or discloses about you for payment or health care operations. The Plan is not required to agree to any restriction that you may request. If the Plan does agree to the restriction, it will comply with the restriction unless the information is needed to provide you with emergency treatment. You may request a restriction by contacting the designated contact listed on the first page of this Notice. It is important that you direct your request for restriction to the designated contact to initiate processing your request. Requests sent to persons or offices other than the designated contact could delay processing the request.
     
    The Plan needs to receive this information in writing and will instruct you where to send your request when you call. In your request please provide: (1) the information whose disclosure you want to limit; and (2) how you want to limit the use and/or disclosure of the information.
  • Right to Request Confidential Communications
    If you believe that a disclosure of all or part of your PHI may endanger you, you may request that the Plan communicate with you regarding your information in an alternative form or at an alternative location. For example, you may ask that the Plan only contact you at your work address or through your work e-mail.
     
    You may request a restriction by contacting the designated contact listed on the first page of this Notice. It is important that you direct you request for confidential communications to the designated contact so that the Plan can begin to process your request. Requests sent to persons or offices other than the one indicated might delay processing the request.
     
    The Plan needs to receive this information in writing and will instruct you where to send your request when you call. In your request please explain: (1) that you want the Plan to communicate your PHI with you in an alternative manner or at an alternative location; and (2) that the disclosure of all or part of the PHI in a manner inconsistent with your instructions would put you in danger.
     
    The Plan will accommodate a request for confidential communications that is reasonable and that states that the disclosure of all or part of your PHI could endanger you. As permitted by the HIPAA Privacy Rule, “reasonableness” will include, when appropriate, making alternate arrangements regarding payment.
     
    Accordingly, as a condition of granting your request, you will be required to provide the Plan information concerning how payment will be handled. For example, if you submit a claim for payment, state or federal law (or the Plan’s own contractual obligations) may require that the Plan disclose certain financial claim information to the plan participant (e.g., an Explanation of Benefits or “EOB”). Unless you have made other payment arrangements, the EOB (in which your PHI might be included) may be released to the plan participant.
     
    Once the Plan receives all of the information for such a request (along with instructions for handling future communications) the request will be processed as soon as practicable. Prior to receiving the information necessary for this request, or during the time it takes to process it, PHI might be disclosed (such as through an EOB). Therefore, it is extremely important that you contact the designated contact listed on the first page of this Notice as soon as you determine that you need to restrict disclosures of your PHI.
     
    If you terminate your request for confidential communications, the restriction will be removed for all of your PHI the Plan holds including PHI that was previously protected. Therefore, you should not terminate a request for confidential communications if you remain concerned that disclosure of your PHI will endanger you.
  • Right to Inspect and Copy
    You have the right to inspect and copy your PHI that is contained in a “designated record set.” Generally, a designated record set contains medical and billing records as well as other records that are used to make decisions about your health care benefits. However, you may not inspect or copy psychotherapy notes or certain other information that may be contained in a designated record set.
     
    To inspect and copy your PHI that is contained in a designated record set, you must submit your request to the designated contact listed on the first page of this Notice. It is important that you contact the designated contact to request an inspection and copying so that the Plan can begin to process your request. Requests sent to persons, offices, other than the designated contact might delay processing the request. 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. The requested information will be provided within thirty (30) days if the information is maintained on site or within sixty (60) days if the information is maintained offsite. A single thirty (30) day extension is allowed if the Plan is unable to comply with this deadline.
     
    The Plan may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your information, you may request that the denial be reviewed. To request a review, you must contact the designated contact listed on the first page of this Notice. A licensed health care professional chosen by us will review your request and the denial. The person performing this review will not be the same one who denied your initial request. Under certain conditions, the denial will not be reviewable. If this event occurs, the Plan will inform you of this fact.
  • Right to Accounting
    You have a right to an accounting of certain disclosures of your PHI that are for reasons other than treatment, payment or health care operations. No accounting of disclosures is required for disclosures made pursuant to a signed authorization by you or your personal representative. You should know that most disclosures of PHI will be for purposes of payment or health care operations, and, therefore, will not be subject to your right to an accounting. There also are other exceptions to this right.
     
    An accounting will include the dates of the disclosure, to whom the disclosure was made, a brief description of the information disclosed, and the purpose for the disclosure.
     
    You may request an accounting by submitting your request in writing to the designated contact listed on the first page of this Notice. It is important that you direct your request for an accounting to the designated contact so that the Plan can begin to process the request. Requests sent to persons or offices other than the designated contact might delay processing the request. If the accounting cannot be provided within sixty (60) days, an additional thirty (30) days is allowed if a written statement explaining the reasons for the delay is provided. Your request may be for disclosures made up to six (6) years before the date of your request but not for disclosures made before April 14, 2003. If you request more than one accounting within a twelve (12) month period, the Plan will charge you the reasonable costs of providing the accounting. The Plan will notify you ofthe cost involved and you may choose to withdraw or modify your request before any costs are incurred.
  • Confidential Communications
    You may ask that the Plan communicate with you in an alternate way or at an alternate location to protect the confidentiality of your PHI. Your request must state an alternate method or location you would like the Plan to use to communicate your PHI to you.
  • Right to a Copy of This Notice
    You have the right to request a copy of this Notice at any time by contacting the designated contact listed on the first page of this Notice. If you receive this Notice on the Plan’s Website or by electronic mail, you are entitled to request a paper copy of this Notice.

CHANGES TO THIS NOTICE

The Plan reserves the right to change this Notice and make any revised Notice effective for health information already on file for you, as well as any health information the Plan receives in the future. The most recent Notice will be posted in a prominent location to which you have access.

COMPLAINTS

You may complain to the Plan if you believe it has violated your privacy rights. You may file a complaint with the Plan by calling the number listed on the first page of this Notice. A copy of a complaint form is available from this contact office.

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. Complaints filed directly with the Secretary must: (1) be in writing; (2) contain the name of the entity you are complaining about; (3) describe the relevant problems; and (4) be filed within 180 days of the time you became or should have become aware of the problem.

The Plan will not penalize or retaliate against you in any way for filing a complaint.

EFFECTIVE DATE
This Notice of Privacy Practices is effective as of April 14, 2003, with updates effective February 16, 2026.

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