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.
This Notice of Privacy Practices describes how we may use
and disclose your protected health information to carry out payment or
healthcare operations and for other purposes that are permitted or required by
law. It also describes your rights to access and control your protected health
information. “Protected health information” (PHI) is information about you,
including demographic information, that may identify you and that relates to
your past, present or future physical or mental health condition and related
healthcare services.
We are required to abide by the terms of this Notice of
Privacy Practices. We may change the terms of our notice at any time. The new
notice will be effective for all protected health information (PHI) that we
maintain at that time.
If you have questions about any part of this Notice or if
you want more information about the privacy practices at Puritan Life Insurance
Company of America, please contact the Privacy Compliance Department at P.O.
Box 10861, Clearwater, Florida 33757-8861 or (866) 398-9305.
How We May Use or Disclose Your Health Information.
The following categories describe the ways that we may use
or disclose your health information. For each category of uses and disclosures,
we will explain what we mean and present some examples. Not every use or
disclosure will be listed, however all the ways we are permitted to use and
disclose information will fall within one of the categories.
Treatment, payment or healthcare operations.
Federal law permits Puritan Life Insurance Company of
America to use and disclose your PHI without your authorization or consent for
the purposes of payment and healthcare operations.
We may use or disclose information about you to determine
eligibility for plan benefits, obtain premiums, facilitate payment for the
treatment or services you receive from healthcare Providers, determine plan
responsibility for benefits, or to coordinate benefits. For example, payment
functions may include sharing PHI with Medicare or other health plans for
purposes of coordination of benefits; reviewing PHI to determine medical
necessity of services received; providing PHI to vendors for the collection and
payment of fees for Prescription Drug Card benefits.
Healthcare operations are the basic business functions
necessary to operate as an insurance plan. Some examples of uses and
disclosures permitted as part of healthcare operations include but are not
limited to, the disclosure of PHI for underwriting, premium rating and other
activities relating to plan coverage; conducting or arranging for medical review,
legal services, audit services, and fraud and abuse detection programs. We may
disclose PHI to consultants who provide legal, actuarial and auditing services
to the plan. Operations also include the use and disclosure of PHI for business
planning, management and general administration of the plan. We will share your
protected health information with third party “business associates” that
perform various activities (e.g., claim administration services) on behalf of
the plan.
Other uses and disclosures permitted without
authorization.
Federal law also allows a health plan to use and disclose
PHI, without your authorization or consent, in the following ways:
The examples of uses and disclosures listed above are not
provided as an all-inclusive list of the ways in which PHI may be used. They
are provided to describe the general uses and disclosures that may be made.
Uses and Disclosures Requiring an Opportunity to Agree or
Disagree
Other uses and disclosures of your PHI will only be made
upon receiving your valid written authorization. You may revoke an
authorization at any time by providing written notice to us that you wish to
revoke an authorization. We will honor a request to revoke as of the day it is
received and to the extent that we have not already used or disclosed your PHI
in good faith with the authorization.
YOUR RIGHTS IN RELATION TO PROTECTED HEALTH INFORMATION
Right to Request Restrictions on Uses and Disclosures.
You have the right to request that the plan limit its uses
and disclosures of PHI in relation to treatment, payment or healthcare
operations or not use or disclose your PHI for these reasons at all. You also
have the right to request the plan restrict the disclosure of PHI to family
members or personal representatives. Any such request must be made in writing
to the Privacy Compliance Office listed in this Notice and must state the
specific restriction and to whom the restriction should apply.
The plan is not required to agree to the restriction that
you request. However, if it does agree to the requested restriction, it may not
violate that restriction except as necessary to allow provision of emergency
medical care to you.
Right to Request Confidential Communications.
You have the right to request that communications
involving PHI be provided to you at an alternative location or by alternative
means. The plan is required to accommodate any reasonable request if the normal
method of disclosure would endanger you and that danger is stated in your
request. Any such request must be made in writing to the Privacy Compliance
Office listed in this notice.
Right to Access Your Protected Health Information.
You have the right to inspect and copy your PHI that is
contained in a designated record set for as long as the plan maintains the PHI.
A designated record set may contain claim information, premium records and any
other records the plan has created in making claim and coverage decisions
relating to you. Federal law prohibits you from accessing the following
records: psychotherapy notes; information complied in the reasonable
anticipation of, or for use in a civil, criminal or administrative action or
proceeding; and PHI that is subject to a law that prohibits access to that
information. If your request for access is denied, you may have a right to have
that decision reviewed. Requests for access to your PHI should be directed to
the Privacy Compliance Office listed in this Notice.
Right to Amend Protected Health Information.
You have the right to request that PHI in a designated
record set be amended for as long as the plan maintains the PHI. The plan may
deny your request for amendment if it determines that the PHI was not created
by the plan, is not part of the designated record set, is not information
available for inspection, or that the PHI is accurate and complete. If your
request for amendment is declined, you have the right to have a statement of
disagreement included with the PHI. The plan has the right to include a
rebuttal to your statement, a copy of which will be provided to you. Requests
for amendment of your PHI should be directed to the Privacy Compliance Office
listed in this Notice.
Right to Receive an Accounting of Disclosures.
You have the right to receive an accounting of all
disclosures of your PHI that the plan has made, if any, for reasons other than
disclosures for treatment, payment or healthcare operations, as described
above, disclosures made to you or your personal representative and disclosures
made pursuant to a valid authorization received from you. Your right to an
accounting of disclosures applies only to PHI created by the plan after April
14, 2003, and cannot exceed a period of six years prior to the date of your
request. Requests for an accounting of disclosures of your PHI should be
directed to the Privacy Compliance Office listed in this Notice.
Right to Receive a Paper Copy of this Notice.
You have the right to receive a paper copy of this Notice
upon request. This right applies even if you have previously agreed to accept
this Notice electronically. Requests for a paper copy of this Notice should be
directed to the Privacy Compliance Office listed in this Notice.
COMPLAINTS
If you believe that your privacy rights have been
violated, you may file a compliant with the plan or the Secretary of Health and
Human Services. The plan will not retaliate against you for filing a complaint.
Complaints filed with the plan should be filed in writing
to:
Privacy Compliance Office
P.O. Box 10861
Clearwater, FL 33757-8861
Complaints to the Secretary of Health and Human Services
should be filed in writing to:
US Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201
If you have any questions regarding this Notice you may
obtain additional information by writing to:
Privacy Compliance Department
PO Box 10861
Clearwater, Florida 33757-8861
Or by calling
(866) 398-9305
EFFECTIVE DATE OF NOTICE
This Notice was published and becomes effective no later
than April 1, 2007.