Effective September 1, 2013
EMPLOYEE WELFARE BENEFIT PLAN RIGHT TO PRIVACY
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.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Belmont University Employee Welfare Benefit Plan to notify plan participants and beneficiaries about its policies and practices to protect the confidentiality of their health information. This document is intended to satisfy HIPAA’s Notice requirement with respect to all health information created, received, transmitted, or maintained by the Belmont University Employee Welfare Benefit Plan (“the Plan"), as sponsored by Belmont University (“the Plan Sponsor”).
Belmont University is committed to protecting the privacy of your medical information. Belmont University will provide the highest level of protection for your medical information, including all records of your medical care that are received by us. The Plan is required by law to:
• make sure that medical information that identifies you is kept private;
• give you this notice of its legal duties and privacy practices with respect to medical information about you; and
• follow the terms of this notice.
Circumstances Under Which the Plan May Use and Disclose Health Information About You:
For Treatment. The Plan may disclose your PHI to a health care provider who renders treatment on your behalf. For example, if you are unable to provide your medical history as the result of an accident, the Plan may advise an emergency room physician about the types of prescription drugs you currently take.
For Payment. The Plan may use and disclose your PHI so claims for health care treatment, services, and supplies you receive from health care providers may be paid according to the Plan’s terms. For example, the Plan may receive and maintain information about surgery you received to enable the Plan to process a hospital’s claim for reimbursement of surgical expenses incurred on your behalf, or the Plan may provide information regarding your coverage or health care treatment to other health plans to coordinate payment of benefits.
For Health Care Operations. The Plan may use and disclose your PHI to enable it to operate or operate more efficiently or make certain all of the Plan’s participants receive their health benefits. When you enroll in the Plan, you are giving consent to the Plan to use and disclose medical information about you so that those who provide you with healthcare services under the Plan may be paid. The Plan may also use and disclose medical information about you for Plan operations. Your medical information may be used without any additional authorization from you for administrative purposes, including:
• enrollment in and removal from the health plan;
• health claims processing and related customer services activities;
• health claim payment and remittance advice such as Explanation of Benefits (EOB) forms;
• determination of eligibility;
• health care premium payments (including payments under COBRA);
• health care claim status;
• coordination of benefits, subrogation, and overpayments;
• conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs;
• medical case management;
• activities relating to reinsurance and filing of reinsurance claims; and
- in compliance with a request from an authorized governmental agency.
Other Uses and Disclosures
- Health-related benefits or services. From time to time, the Plan may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
- Business Associates. The Plan may contract with individuals or entities known as Business Associates to perform various functions or services for the Plan. Business Associates must agree in writing to implement appropriate safeguards regarding your protected health information.
- Disclosures required by law. The Plan will disclose medical information about you when required to do so by federal, state, or local law.
- Health oversight activities. The Plan may disclose medical information to a health oversight agency for activities authorized by law. These activities may include, but are not limited to, audits, investigations, and inspections. These activities are necessary for the government to monitor the health care system, the delivery of health care, etc.
- 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 order or administrative order. It 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.
- 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. Other related disclosures may include disclosures to national security and intelligence agencies, as well as disclosures to authorized federal officials for the protection of the president of the United States or other authorized persons or foreign heads of state.
- Military and Veterans. The Plan may release medical information about you as required by military command authorities.
- Decedents. The Plan may disclose medical information about you to a coroner, medical examiner, or funeral director to permit them to carry out their legal duties.
- Organ and Tissue Donation. The Plan may release medical information to organizations for the purpose of facilitating organ, eye or tissue donation and transplantation.
- Plan sponsor. The Plan may, from time to time, disclose information about you to the Plan Sponsor, Belmont University, for purposes of administering the Plan.
- Public health risks. The Plan may disclose medical information about you for public health activities.
- Serious threat to health or safety. The Plan may use and disclose medical information about you when it is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
- Workers’ Compensation. The Plan may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Written permission. Other uses and disclosures of your medical information not covered by this notice or the laws that apply to the Plan will be made only with your written permission. You may revoke your permission at any time in writing. If you revoke your permission, the Plan will no longer use or disclose medical information about you for the reasons covered by your authorization. Use or disclosure of your medical information prior to you revoking permission is allowable.
Your Rights Regarding Your Medical Information
You have the right to inspect and copy medical information that may be used to make decisions about your medical care. Usually this right includes both medical and billing records. You must submit your request in writing to the Belmont
University Employee Welfare Benefit Plan, Benefit Plan HIPAA Privacy Official. The current Employee Welfare Benefit Plan HIPAA Privacy Official is the Director of Human Resources. Assistant Director of Human Resources may also be contacted for all Belmont University Employee Welfare Benefit Plan questions or issues. The mailing address is: Office of Human Resources, 1900 Belmont University, Nashville, TN 37212.
If the information you request is maintained electronically, and you request an electronic copy, the Plan will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format; if the information cannot be readily produced in that form and format, the Plan will work with you to come to an agreement on form and format. The Plan may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. Your request to inspect and copy your information may only be denied in very limited circumstances, and you have a right to request that any such denial be reviewed.
You have the right to request that the Plan restrict the use of your medical information for treatment, payment, and health care operations. The Plan is not required to agree to your request. If it does agree, it will comply with your request unless the information is needed to provide you with emergency treatment under the Plan. To request restrictions, you must make your request in writing to the Benefit Plan HIPAA Privacy Official and specify:
- what information you want to limit;
- whether you want to limit its use, disclosure, or both; and
- to whom you want the limits to apply.
You also have the right to request to receive private health information communications (such as EOBs) by alternative means or at alternative locations. For example, you may ask that you only be contacted at work or by mail. To request confidential communications, you must make your request in writing to the Employee Welfare Benefit Plan HIPAA Privacy Official and specify how and/or where you wish to be contacted.
If you feel that your medical information is incorrect or incomplete, you have the right to request that your medical information be amended. The health care entity (i.e., doctor, hospital, clinic, etc.) that created your medical information is responsible for amending it.
You have a right to an accounting of disclosures of your medical information for purposes other than payment or health care operations by the Plan or any of the people or companies who perform payment or health care operations on behalf of the Plan. To request a list of disclosures, you must submit a request in writing to the Employee Welfare Benefit Plan HIPAA Privacy Official. Your request must state a time period, which may not be longer than six years prior to the date of your request. Your request should indicate the form in which you want the information (for example, paper or electronically). The Plan may charge a reasonable fee for processing your request.
You have the right to receive written notification if the Plan discovers a breach of your unsecured protected health information and determine that notification is required.
Your Personal Representative
You may exercise your rights to your PHI by designating a personal representative. Your personal representative will be required to produce evidence of the authority to act on your behalf before the personal representative will be given access to your PHI or be allowed to take any action for you. Under this Plan, proof of such authority will be a completed, signed and approved Personal Representative form. You may obtain this form by contacting the Employee Welfare Benefit Plan HIPAA Privacy Official’s office or by downloading the appropriate form from the Office of Human Resources web site at www.belmont.edu/hr.
The Plan retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. The Plan will consider a parent, guardian, or other person acting in loco parentis as the personal representative of an unemancipated minor (a child generally under age 18) unless the applicable law requires otherwise. In loco parentis may be further defined by state law, but in general it refers to a person who has been treated as a parent by the child and who has formed a meaningful parental relationship with the child for a substantial period of time.
Changes to This Notice
The Plan reserves the right to change this notice and to make the revised or changed notice effective for protected health information we already have about you, as well as any information we receive in the future. A copy of the most current notice will be available at the Belmont University Office of Human Resources website: www.belmont.edu/hr. The notice will contain, in the top right-hand corner, the effective date. If this notice is changed in the future, you will receive notification and will be provided with information on how to obtain a copy of the revised notice. It will also be posted on the Belmont University Office of Human Resources website.
If you believe your privacy rights have been violated and that the Plan has not followed this notice, you may file a complaint with the Employee Welfare Benefit Plan HIPAA Privacy Official or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
If you have any questions regarding this notice, contact the Benefit Plan HIPAA Privacy Official at (615) 460-6456.
Your medical treatment providers (i.e., doctors, hospitals, home health agencies, etc.) may have different policies or notices regarding the use and disclosure of your medical information. If you have questions about your provider’s privacy policies, please contact your provider directly.