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.
Protected Health Information (PHI) is any information about your health, your health insurance or health services that you get. PHI also includes information that is created and kept by the Plan. Examples of this type of information are your enrollment in the Plan, your past, present or future physical or mental health condition, health care you have received, or payment for the health care you have received. We are required by law to:
- Keep your PHI private
- Give you this notice as required by the Health Insurance Portability and Accountability Act (HIPAA)
- Follow the policies and procedures in this notice
This notice is given to our members when they enroll with the Plan. We can change this notice at any time. You will be notified of any big changes and may request a copy of this notice at any time.
How We May Use and Share Your PHI
There are times when we can use and share your PHI without your direct permission. These times are described below.
- For Treatment: We may use or share PHI to do business activities. These activities include things like:
- For Health Care Operations: The Plan may use or disclose PHI in order to support the business activities of the Plan. These activities include such things as:
- Using PHI to find out if the Plan is meeting quality goals and standards
- For programs that support early detection of diseases, prevention of diseases or case management of diseases
- Sharing PHI with people and companies that help manage your care
- Sharing PHI with people and companies that help us perform business. We will only share information if there is a business reason to share it and if there is a signed agreement in place to protect your PHI
- We may use or share your PHI to give you more information about the Plan or about treatments. For example, we may use your name and address to send a you a newsletter or other information about our activities
Allowed And Required Uses And Sharing of Your PHI
We may use or share your PHI without your permission if required by state and federal laws. We may share your PHI:
- When required by law or for public health reasons. If we need to give you information about benefits you can get under your plan or in some situations, about health-related products or services that may be of interest to you.
- If law enforcement or specific government agencies ask us through a court order, subpoena, warrant, summons or similar process.
- PHI may be released for law enforcement or specific government functions. These include a request by a law enforcement official made through a court order, subpoena, warrant, and summons or from a similar process.
We will protect your Personal Health information and make sure that all sharing of this information follows the rules above. If we use or share your information for any other reason, we will get your written permission.
You must sign a special agreement and send it to us so we can share your information. For example, you may agree in writing that the Plan may share information with another person or company such as a caregiver. Remember that once we get permission to share information, we cannot be certain that the person who gets the information from us will not share it with someone else.
Again, the only time we would not need your permission is if the use or sharing of this information is allowed or required by law.
Your Rights With PHI
You have rights about your protected PHI.
You have the right to look at and get a copy your PHI. You may look at and get a copy of PHI that is part of a designated record set for as long as we keep this information on file. A designated record set means medical and billing records, and any other records that are used by the Plan. You may have to pay a small fee for the costs of copying, mailing or other materials. Your must ask for this in writing. Please send it to the Grievance/Appeals & Privacy Administrator at PacificSource Community Solutions, PO Box 5729, Bend OR 97701, and we will answer your request within 30 days. If for any reason this information is not in our office, we will answer within 60 days. You may not be able to get some types of PHI like psychotherapy notes or PHI collected by us in preparation for any legal actions.
You have the right to ask that the Plan change or modify your PHI. You may ask that the Plan change information that is in a designated record set. We may or may not agree to what you ask. You must ask us in writing and we will answer whether or not we will make the change. If you do not agree with our answer, you may tell us in writing why you do not agree. We may not agree with what you ask if the information is:
- Not correct or complete
- Was not created by the Plan
- Necessary to meet with state and federal regulations
You have the right to a list of those we have shared your PHI with. This listing will not include those that we have shared PHI with for the purposes of treatment, payment, health care operations, or as required by law as listed above. This list will not include any information prior to April 14, 2003. You must ask us in writing and tell us the dates you want us to include.
You have the right to restrict or limit us from using your PHI. We may review what you are asking us but we are not required to agree to it. To ask us to limit PHI we may use, you must ask us in writing and tell us what information you want to limit and the dates involved. If we do not agree to what you ask, we will send you a letter. We cannot agree to restrict PHI that we are legally required to share, or that is necessary for treatment, payment, or health care operations.
We can communicate with you in different ways. You have the right to ask that we communicate with you in a certain way, such as by telephone or mail. You can also ask that we communicate with you at a certain place, such as sending mail to a specific address. You must ask us in writing. We will review and agree to all reasonable requests.
You have the right to ask us for a copy of this notice at any time.
Using Your Rights And Complaints
If you think your privacy has been shared when it should not have been,, you may send a written complaint to our Privacy Contact. We will not react against you for your complaint. Please send your complaint to:
PacificSource Community Solutions
Attn: Grievance/Appeals & Privacy Administrator
PO Box 5729
Bend, OR 97708-5729
You may also send your complaints to the US Department of Health and Human Services:
U.S. Department of Health and Human Services
200 Independence Ave. SW
Room 509F, HHH Building
Washington DC 20201
If you have any questions please call Customer Service at:
(541) 382-5920 Local
(800) 431-4135 Toll Free
(800) 735-2900 TTY
Privacy rules are overseen by the Compliance Officer, who also acts as the Privacy Officer.
This notice is effective April 14, 2003.