SecondSight Radiology, LLC
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 THIS NOTICE CAREFULLY.
This Notice of Privacy Practices describes the types of health related information collected by the Benefit Programs that provide group health benefits. The Plan is required by law to maintain the privacy of your Protected Health Information, except for the legally allowed uses and disclosures described below.
“Protected Health Information” means information sent or maintained by the Company that can be used to identify you in your capacity as a patient or applicant for health care treatment, payment or operations (“PHI”). The Company obtains PHI from your applications for health care coverage, and from surveys, claims for payment filed by health care providers, referrals made by health care providers, and your medical records. The Company may obtain PHI over the telephone from you. Other sources of your PHI include group health plan administrators, employers, and your employer’s business partners such as third-party administrators, consultants and other entities engaged in obtaining health care information for the Company.
Protected Health Information (PHI) includes the information about your:
- Health history
- Medical records
- Name, address, and date of birth
- Marital status
- Gender and sexual orientation
- Social security number
- Other similar information that relates to past, present or future medical care
STATEMENT OF POLICY
YOU HAVE RIGHTS
To review your PHI that is held by or under the control of the Company, its business associates and to obtain a copy of such information. Your request should be in writing; and you may be charged a reasonable fee for the copies.
To request amendments to your PHI, your request for amendments must be made in writing and include the reason for the amendment.
To register a complaint concerning your PHI, you should follow our Complaint Procedure, and your complaint should be in writing.
To request an accounting of disclosures of your PHI made by the Company or its business associates, your request must be made in writing and may cover disclosures made during a period of up to the previous six years.
To request a restriction on your PHI that may be disclosed, your request must be written. Your health care provider is not required to agree to this request.
You also have the right to request that communication regarding your PHI from your health care provider be made at a certain time or location. This request must be in writing. Your health care provider should accommodate all reasonable requests.
USE AND DISCLOSURE FOR TREATMENT
The Company may disclose your PHI to health care providers including doctors, nurses, laboratory technicians, medical students and other health care personnel involved in your treatment.
USE AND DISCLOSURE FOR PAYMENT
The Company may disclose your PHI to a business associate of the Company that is involved in payment for your treatment. The Company may share your PHI with persons involved in utilization review, to assist in subrogation of health care claims, or other adjudication procedures.
USE AND DISCLOSURE FOR HEALTH CARE OPERATIONS
The Company may disclose your PHI for program operation purposes including underwriting, premium rating, submitting claims for stop-loss coverage, quality review assessments, audits, business planning, legal services or administrative services.
The Company may share your PHI with its business partners for purposes of utilization reviews, appropriateness of care reviews, consultation with outside health care providers, consultants and attorneys. We require the Company’s business partners to sign a contract specifying their compliance with HIPAA privacy policies.
NON-ROUTINE DISCLOSURES OF PERSONAL HEALTH INFORMATION
In situations not covered by your consent, your health care provider will ask for your authorization to use or disclose your PHI. This may be to release your PHI for workers’ compensation purposes, automobile insurance claims, marketing or research purposes. Your health care provider will use or disclose PHI only in the circumstance and for the specific purpose contained in your authorization; and will use or disclose the minimum amount of PHI necessary to perform the non-routine function. Generally, you are the only person who can authorize the use or disclosure of your PHI. In some circumstances, authorization may be obtained from a person representing your interests (such as in the case where you may be too incapacitated to make an informed authorization), or in emergency situations where it would be impractical to obtain authorization.
The Company may make non-routine disclosures to:
- the Plan Sponsor (with your consent) for payment or other claims purposes
- Organ donation and tissue transplant entities, if you are an organ or tissue donor
- The military if you are a member of the armed services
- Workers’ compensation carriers
- Public health agencies
- Law enforcement personnel
- Coroners, medical examiners and funeral directors
- Legal representatives in response to a court order
- National security and intelligence agencies
- Correctional institutions
HOW YOU CAN GET MORE INFORMATION
If you have any questions about this notice or the topics it covers, you may contact the SecondSight Radiology, LLC, at email@example.com.
CHANGES TO PRIVACY PRACTICES
SecondSight Radiology, LLC may change its Notice of Privacy Practices for the Company. In that case, an updated Notice of Privacy Practices will be provided to you.
This notice is published and becomes effective on January 2, 2013