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Required Notices PRMC Health Plan

Eff 11/01/10
STATEMENT OF GRANDFATHERED HEALTH PLAN
This group health plan believes this plan is a “grandfathered health plan” under
the Patient Protection and Affordable Care Act (the Affordable Care Act). As
permitted by the Affordable Care Act, a grandfathered health plan can preserve
certain basic health coverage that was already in effect when that law was
enacted. Being a grandfathered health plan means that your plan may not include
certain consumer protections of the Affordable Care Act that apply to other plans,
for example, the requirement for the provision of preventive health services
without any cost sharing. However, grandfathered health plans must comply with
certain other consumer protections in the Affordable Care Act, for example, the
elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply
to a grandfathered health plan and what might cause a plan to change from
grandfathered health plan status can be directed to the Claims Administrator,
Benefit Management, Inc., PO Box 1090, Great Bend, KS 67530, (620) 792-1779.
You may also contact the Employee Benefits Security Administration, U.S.
Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This
website has a table summarizing which protections do and do not apply to
grandfathered health plans.
CS02_SEWHCRA 1511
NOTICE OF SPECIAL ENROLLMENT RIGHTS
Federal law provides Special Enrollment provisions under some circumstances. If you are declining enrollment
for yourself or your dependents (including spouse) because of other health insurance coverage, you may in the
future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 63
days after your other coverage ends.
There may be a right to enroll in this Plan if you or your dependent lose coverage under Medicaid or a State
Children’s Health Insurance Program, or you or your dependent become eligible for Plan assistance under
Medicaid or a State Children’s Health Insurance Program (including under any waiver or demonstration project
conducted under or in relation to such a program). Enrollment must be requested within 63 days of the Special
Enrollment event.
In addition, if you have a new dependent as a result of marriage, birth, adoption, placement for adoption, or
legal guardianship you may be able to enroll yourself and your dependents, provided that you request
enrollment within 63 days after the marriage, birth, adoption, placement for adoption or court appointed date of
legal guardianship.
WOMEN’S HEALTH AND CANCER RIGHTS ACT
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s
Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits,
coverage will be provided in a manner determined in consultation with the attending physician and the patient
for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedemas.
These benefits will be provided subject to the same deductibles and co-insurances applicable to other medical
surgical benefits provided under this plan. Therefore, the following deductible and co-insurance applies:
Option
1 Pratt Regional Medical Center Basic Plan Core Provider Network $600 deductible and 70% coinsurance,
PPO Provider Network $1,200 deductible and 70% coinsurance. Option 2 Pratt Regional Medical Center
Standard Plan Core Provider Network $360 deductible and 80% coinsurance, PPO Provider Network $720
deductible and 80% coinsurance. Option 3 Pratt Regional Medical Center Premium Plan Core Provider
Network $240 deductible and 80% coinsurance, PPO Provider Network $480 deductible and 80% coinsurance.
If you would like more information on WHCRA benefits, call the Claims Administrator at (800) 290-1368 or
(620) 792-1779.
Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and youre eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using funds from
their Medicaid or CHIP programs. If you or your children arent eligible for Medicaid or CHIP, you wont be
eligible for these premium assistance programs but you may be able to buy individual insurance coverage
through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact
your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under
your employer plan, your employer must allow you to enroll in your employer plan if you arent already enrolled.
This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
determined eligible for premium assistance. If you have questions about enrolling in your employer plan,
contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health
plan premiums. The following list of states is current as of July 31, 2016. Contact your State for more
information on eligibility
ALABAMA Medicaid
FLORIDA Medicaid
Website: http://myalhipp.com/
Phone: 1-855-692-5447
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268
ALASKA Medicaid
GEORGIA Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility:
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
Website: http://dch.georgia.gov/medicaid
- Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507
ARKANSAS Medicaid
INDIANA Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.hip.in.gov
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
COLORADO Medicaid
IOWA Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
Website: http://www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
2
CS02_CMN 1611
KANSAS Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-785-296-3512
KENTUCKY Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA Medicaid
Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
MAINE Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-
assistance/index.html
Phone: 1-800-442-6003
TTY: Maine relay 711
MASSACHUSETTS Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
MINNESOTA Medicaid
Website: http://mn.gov/dhs/ma/
Phone: 1-800-657-3739
MISSOURI Medicaid
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht
m
Phone: 573-751-2005
MONTANA Medicaid
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIP
P
Phone: 1-800-694-3084
NEBRASKA Medicaid
Website:
http://dhhs.ne.gov/Children_Family_Services/AccessNe
braska/Pages/accessnebraska_index.aspx
Phone: 1-855-632-7633
NEVADA Medicaid
SOUTH CAROLINA Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
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CS02_CMN 1611
SOUTH DAKOTA - Medicaid
WASHINGTON Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/free-or-low-cost-
health-care/program-administration/premium-
payment-program
Phone: 1-800-562-3022 ext. 15473
TEXAS Medicaid
WEST VIRGINIA Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
Website:
http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/
Pages/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH Medicaid and CHIP
WISCONSIN Medicaid and CHIP
Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
Website:
https://www.dhs.wisconsin.gov/publications/p1/p10095.
pdf
Phone: 1-800-362-3002
VERMONT Medicaid
WYOMING Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
VIRGINIA Medicaid and CHIP
Medicaid Website:
http://www.coverva.org/programs_premium_assistance.
cfm
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.
cfm
CHIP Phone: 1-855-242-8282
To see if any other states have added a premium assistance program since July 31, 2016, or for more information
on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 11/30/2016)
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Pratt Regional Medical Center Organized Health Care Arrangement
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 IT CAREFULLY.
This Notice describes the legal obligations of Pratt Regional Medical Center Organized Health
Care Arrangement (the “Plan”) and your legal rights regarding your protected health information held by
the Plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Plan is
required by law to maintain the privacy of protected health information and to provide you with this
Notice of its legal duties and privacy practices with respect to protected health information. This Notice
describes the circumstances under which your protected health information may be used or disclosed by
the Plan to carry out treatment, payment or health care operations or for any other purpose that is
permitted or required by law.
In general, “protected health information” is individually identifiable information, including
demographic information, collected from you or created or received by a health care provider, a health
care clearinghouse, a health plan, including the Plan, or by Pratt Regional Medical Center on behalf of the
Plan, that relates to the following:
(1) Your past, present or future physical or mental health or condition;
(2) The provision of health care to you; or
(3) Your past, present or future payment for the provision of health care to you.
I. The Plan’s Responsibilities Regarding Protected Health Information
Pratt Regional Medical Center Employee Health Care Plan and Pratt Regional Medical Center Flexible
Spending Account Program Benefits Plan have, for purposes of complying with the HIPAA medical
privacy regulations, formed an organized health care arrangement that is referred to in this Notice as the
Plan. An organized health care arrangement (“OHCA”) is authorized to issue a joint Notice of Privacy
Practices and develop one set of policies and procedures applicable to all group health plans that are
members of the OHCA. Group health plans that are members of an OHCA are authorized to share
protected health information with each other as necessary to carry out treatment, payment or health care
operations and as necessary to manage and operate the organized health care arrangement. Each group
health plan that is a member of the Plan is considered “self-funded.” The Plan, on behalf of its individual
members, is required by law to:
Protect and maintain the privacy of your protected health information in accordance with
HIPAA;
Provide you with certain rights relating to your protected health information;
Prepare and maintain this Notice of our legal duties and privacy practices with respect to
your protected health information;
Provide a copy of this Notice to you;
Provide a copy of this Notice to an individual at the time he or she enters a group health
plan that is a member of the Plan;
Within 60 days of a material modification of this Notice, provide a copy of the revised
Notice to you;
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No less frequently than every three years, notify all individuals enrolled in a group health
plan that is a member of the Plan of the availability of this Notice and how to obtain a
copy; and
Follow the terms of the Notice that is currently in effect.
II. How the Plan May Use and/or Disclose Your Protected Health Information
The following categories describe different ways that the Plan may use and/or disclose your
protected health information. For each category, use or disclosure, this Notice will explain what is meant
and will present some examples. Not every use or disclosure in a category will be listed. However, all
the ways the Plan is permitted to use and disclose your protected health information will fall within one of
the categories.
For Treatment. The Plan may disclose your protected health information to your health care
provider for its provision, coordination or management of your health care and related services. For
example, the Plan may disclose your protected health information to your health care provider for
purposes of coordinating your health care with the Plan or referring you to another provider for care.
For Payment. The Plan may use and disclose your protected health information to determine
eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health
care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For
example, the Plan may tell your health care provider about your medical history to determine whether a
particular treatment is experimental, investigational, or medically necessary, or to determine whether the
Plan will cover the treatment. The Plan may also share medical information with a utilization review or
pre-certification service provider. Likewise, the Plan may share protected health information with
another entity to assist with the adjudication or subrogation of health claims or to another health plan to
coordinate benefit payments.
In addition, an explanation of benefits (“EOB”), which may contain information such as the name of the
individual receiving treatment, the name of the health care provider, the date medical care is received, the
amount charged for medical care, and the amount paid for medical care, may be sent to the individual
through whom coverage is provided. For example, a covered employee may receive an EOB disclosing
the information listed above with respect to his or her spouse or any dependents covered through such
employee. This disclosure for payment purposes is subject to an individual’s right to request confidential
communications as explained in Section V below.
For Health Care Operations. The Plan may use and disclose your protected health information
for Plan operations. These uses and disclosures are necessary to run the Plan. For example, we may use
protected health information in connection with conducting quality assessment and improvement
activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims
for stop-loss (or excess loss) coverage; conducting or arranging for medical review, legal services, audit
services, and fraud and abuse detection programs; business planning and development such as cost
management; and business management and general Plan administrative activities.
As Required By Law. The Plan will disclose medical information about you when required to
do so by federal, state or local law. For example, the Plan may disclose your protected health information
when required by national security laws or public health disclosure laws.
To Avert a Serious Threat to Health or Safety. The Plan may use and disclose your protected
health information when necessary to prevent a serious threat to your health and safety or the health and
safety of the public or another person. Any disclosure, however, would only be to someone able to help
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prevent the threat. For example, we may disclose medical information about you in a proceeding
regarding the licensure of a physician.
To a Business Associate. The Plan may enter into contracts with individuals or entities known
as Business Associates to perform various functions on behalf of the Plan or to provide certain types of
services to the Plan. To the extent necessary to perform these functions or to provide these services,
Business Associates may receive from the Plan, create from information provided from the Plan,
maintain, use, and/or disclose your protected health information, but only after they agree in writing with
the Plan to implement and follow appropriate safeguards regarding your protected health information.
For example, the Plan may disclose your protected health information to a Business Associate to
administer claims or to provide support services, such as utilization management, pharmacy benefit
management, or subrogation, but only after the Business Associate agrees in writing to protect your
protected health information to the same extent as the Plan.
To the Plan Sponsor. The Plan may disclose your protected health information to certain
employees of Pratt Regional Medical Center for purposes of administering the Plan. However, those
employees will only use or disclose the information received only as necessary to perform Plan
administrative functions or as otherwise required by HIPAA, unless you have authorized further
disclosures. Your protected health information may not be used for employment purposes without your
specific authorization.
Military and Veterans. If you are a member of the armed forces, the Plan may disclose your
protected health information as required by military command authorities. We may also release protected
health information about foreign military personnel to the appropriate foreign military authority.
Workers’ Compensation. The Plan may disclose protected health information about you for
workers’ compensation or similar programs. These programs provide benefits for work-related injuries or
illness.
Organ and Tissue Donation. If you are an organ donor, the Plan may disclose protected health
information about you to organizations that handle organ donor procurement or transplantation, as
necessary to facilitate organ or tissue donation and transplantation.
Public Health Risks. The Plan may disclose your protected health information for public health
activities. These activities generally include the following:
to prevent or control disease, injury or disability;
to report births and deaths;
to report child abuse or neglect;
to report reactions to medications or problems with products;
to notify people of recalls of products they may be using;
to notify a person who may have been exposed to a disease or may be at risk for contracting
or spreading a disease or condition; or
to notify the appropriate government authority if we believe a participant has been the victim
of abuse, neglect or domestic violence. We will only make this disclosure if you agree or
when required or authorized by law.
Health Oversight Activities. The Plan may disclose your protected health information to a
health oversight agency for activities authorized by law. These oversight activities include, for example,
audits, investigations, inspections, and licensure. These activities are necessary for the government to
monitor the health care system, government programs, and compliance with civil rights laws.
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Coroners, Medical Examiners and Funeral Directors. The Plan may disclose your protected
health information to a coroner or medical examiner. This may be necessary, for example, to identify a
deceased person or determine the cause of death. The Plan may also disclose protected health
information to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. The Plan may disclose your protected health
information to authorized federal officials for intelligence, counterintelligence, and other national security
activities authorized by law.
Inmates. If you are an inmate of a correctional institution or under the custody of a law
enforcement official, the Plan may disclose your protected health information to the correctional
institution or law enforcement official. This release would be necessary (1) for the institution to provide
you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the
safety and security of the correctional institution.
Research. The Plan may disclose your protected health information to researchers when (1) all
individual identifying information has been removed; or (2) when an institutional review board or privacy
board (a) has reviewed and approved the research proposal, and (b) has established protocols to ensure the
privacy of the requested information.
III. Circumstances under Which the Plan Must Disclose Your Protected Health Information
The Plan is required by law to make disclosures of your protected health information in the
following circumstances:
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, the Plan may disclose your
protected health information in response to a court or administrative order. The Plan may also disclose
your protected health information 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 disclose your protected health information if asked to do so by
a law enforcement official:
in response to a court order, subpoena, warrant, summons or similar process;
to identify or locate a suspect, fugitive, material witness, or missing person;
about the victim of a crime if, under certain limited circumstances, we are unable to obtain
the person’s agreement;
about a death we believe may be the result of criminal conduct;
about criminal conduct at the hospital; or
in emergency circumstances to report a crime; the location of the crime or victims; or the
identity, description or location of the person who committed the crime.
In Connection with Government Audits. The Plan is required to disclose your protected health
information to the Secretary of the United States Department of Health and Human Services when the
Secretary is investigating or determining our compliance with HIPAA.
Disclosures to You. When you request, the Plan is required to disclose to you the portion of your
protected health information that contains medical records, billing records, and any other records used to
make decisions regarding your health care benefits. The Plan is also required, when requested, to provide
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you with an accounting of most disclosures of your protected health information, where the disclosure
was for reasons other than for payment, treatment or health care operations, and where the disclosure was
not pursuant to your written authorization.
IV. Other Uses of Protected Health Information
Except where specifically allowed by federal law, the use and disclosure of psychotherapy notes,
use and disclosure of protected health information for marketing purposes, and any disclosure that
constitutes a sale of protected health information will be made only pursuant to your written
authorization. Other uses and disclosures of your protected health information not otherwise described in
this Notice or the laws that apply to the Plan will be made only with your written permission. If you give
the Plan permission to use or disclose your protected health information, you may revoke that permission,
in writing, at any time. If you revoke your permission, the Plan will no longer use or disclose your
protected health information for the reasons covered by your written authorization. However, this will
not affect any disclosures that have already been made with your permission.
V. Your Rights Regarding Your Protected Health Information
You have the following rights regarding medical information maintained by the Plan about you:
Right to Inspect and Copy. You have the right to inspect and copy certain protected health
information that may be used to make decisions about your Plan benefits. To inspect and copy medical
information that may be used to make decisions about you, you must submit your request in writing to the
Contact Person (see section VIII below). The Plan has prepared and will provide to you upon request a
“Request For Access to Protected Health Information” form that may be used by you for this purpose. To
request a copy of this form, please contact the Contact Person. If you request a copy of the information,
we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
In very limited circumstances, the Plan may deny your request to inspect and copy protected
health information that may be used to make decisions about your Plan benefits. If you are denied access
to your protected health information that may be used to make decisions about your Plan benefits, you
may request that the denial be reviewed by submitting a written request to the Contact Person (see section
IX below).
Right to Amend. If you feel that protected health information the Plan has about you is incorrect
or incomplete, you may ask the Plan to amend the information. You have the right to request an
amendment for as long as the information is kept by or for the Plan. To request an amendment, your
request must be made in writing and submitted to the Contact Person (see section VIII below). The Plan
has prepared and will provide to you upon request a “Request to Amend Protected Health Information”
form that may be used by you for this purpose. To request a copy of this form, please contact the Contact
Person. You must provide a reason that supports your request. The Plan may deny your request for an
amendment if it is not in writing or does not include a reason to support the request. In addition, the Plan
may deny your request if you ask the Plan to amend information that:
Is not part of the medical information kept by or for the Plan;
Was not created by the Plan, unless the person or entity that created the information is no
longer available to make the amendment;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.
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If the Plan denies your request, you have the right to file a statement of disagreement with the
Plan and any future disclosures of the disputed information will include your statement.
Right to an Accounting of Disclosures. You have the right to request an accounting of certain
disclosures of your protected health information. The accounting will not include (1) disclosures for
purposes of treatment, payment, or health care operations, unless it involves a disclosure of an electronic
record of health-related information on an individual that is created, gathered, managed and consulted by
authorized healthcare clinicians and staff; (2) disclosures made to you; (3) disclosures made pursuant to
your authorization; (4) disclosures made to friends or family in your presence or because of an
emergency; (5) disclosures for national security purposes; and (6) disclosures incidental to otherwise
permissible disclosures.
To request this list or accounting of disclosures, you must submit your request in writing to the
Contact Person (see section VIII below). The Plan has prepared and will provide to you upon request a
“Request for Accounting of Disclosures of Protected Health Information” form that may be used by you
for this purpose. To request a copy of this form, please contact the Contact Person. Your request must
state a time period, which may not be longer than six years (or three years in the case of disclosures
involving electronic health records, as described above) and may not include dates before the date on
which the Plan was established. Your request should indicate in what form you want the list (for
example, paper or electronic). The first list you request within a 12-month period will be free. For
additional lists, the Plan may charge you for the cost of providing the list. The Plan will notify you of the
cost involved and you may choose to withdraw or modify your request at that time before any costs are
incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on your
protected health information that the Plan uses or discloses about you for treatment, payment or health
care operations. You also have the right to request a limit on your protected health information disclosed
by the Plan to someone who is involved in your care or the payment for your care, like a family member
or friend. For example, you could ask that the Plan not use or disclose information about a surgery you
had. The Plan is not required to agree to your request. However, if your request relates to restricting the
disclosure to another health plan of your protected health information pertaining solely to a health care
item or service for which the health care provider has been paid out-of-pocket in full and where the
purpose of the disclosure would have been for carrying out payment or health care operations, the Plan
must agree to your request.
To request restrictions, you must make your request in writing to the Contact Person (see section
VIII below). The Plan has prepared and will provide to you upon request a “Request for Restrictions to
Protected Health Information” form that may be used by you for this purpose. To request a copy of this
form, please contact the Contact Person. In your request you must tell the Plan (1) what information you
want to limit; (2) whether you want to limit the Plan’s use, disclosure or both; and (3) to whom you want
the limits to apply, for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right to request that the Plan
communicate with you about medical matters in a certain way or at a certain location. For example, you
can ask that the Plan only contact you at work or by mail.
To request confidential communications, you must make your request in writing to the Contact
Person (see section VIII below). The Plan has prepared and will provide to you upon request a “Request
for Confidential Communications” form that may be used by you for this purpose. To request a copy of
this form, please contact the Contact Person. Generally, the Plan is not obligated to grant your request for
confidential communications unless you provide information establishing that disclosure of all or part of
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your protected health information in a manner or at a location other than that requested could endanger
you and the request is reasonable. Your request must specify how or where you wish to be contacted.
Right to Be Notified Following a Breach of Unsecured Protected Health Information. The
Plan is required by law to notify you in the event of a breach of your unsecured protected health
information.
Right to Opt Out of Fundraising Communications. You have the right to opt out of receiving
fundraising communications from the Plan, in the event that the Plan engages in such communications.
Prohibition on Use or Disclosure of Genetic Information. The Plan is prohibited from using
or disclosing protected health information that relates to your genetic information for underwriting
purposes.
Right to Obtain Electronic Copies of Protected Health Information. You have the right to
obtain electronic copies of your protected health information if maintained in a designated record set.
You may request a specific format to receive the electronic protected health information and the Plan will
comply with such request if feasible. You may be charged a reasonable cost-based fee for the electronic
protected health information.
Right to Request Paper Copy of This Notice. You have the right to a paper copy of this Notice.
You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this Notice,
please contact the Contact Person (see section VIII below).
VI. Effective Date
This Notice is effective January 01, 2016.
VII. Changes to this Notice
The Plan reserves the right to change this Notice. The Plan reserves the right to make the revised
or changed notice effective for protected health information that the Plan already has about you as well as
any information the Plan creates or receives in the future.
VIII. Questions About this Notice
If you have any questions about this Notice or would like to receive a copy of this Notice or any
of the forms referenced in this Notice, please contact the Plan’s Contact Person. The Plan’s Contact
Person is Vikki Mader, Director of HM, who may be contacted at 200 Commodore, Pratt KS 67124 or by
telephone at (620) 672-7451.
IX. Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Plan or
with the United States Department of Health and Human Services, Office of Civil Rights. To file a
complaint with the Plan, contact Vikki Mader, Director HM, at 200 Commodore, Pratt KS 67124. All
complaints must be submitted in writing. To file a complaint with the Office of Civil Rights, contact the
United States Department of Health and Human Services, Office of Civil Rights, 601 E. 12
th
Street
Room 353, Kansas City MO 64106. You will not be penalized or retaliated against for filing a complaint.