Effective April 14, 2004
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 practices of the following group health plans and benefits (collectively, the “Plan”) sponsored by St. Olaf College:
- St. Olaf College Comprehensive Major Medical Health Care Plan
- St. Olaf College Dental Plan
- Medical Care Reimbursement Benefit component of the St. Olaf College Flexible Benefits Plan
- St. Olaf College Employee Assistance Program (EAP)
This notice will apply to you to the extent you participate in these plans/benefits. If you participate in other health plans, y ou may receive other notices.
The Plan must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on the date shown at the top of this form, and will remain in effect until it is replaced. The Plan reserves the right to change its privacy practices and the terms of this notice at any time, and to make such changes effective for all personal health information that the Plan maintains, including information created or received before the changes were made. Revised notices will be distributed if significant changes are made.
For more information about the Plan’s privacy practices, please contact the Plan using the information listed at the end of this notice.
The Plan creates and maintains a record of health care claims reimbursed under the Plan and other personal health information about you related to the Plan. The Plan is required by law to maintain the privacy of your personal health information and to provide you with this notice. This notice explains the Plan’s legal duties and privacy practices, and your rights regarding your personal health information. The Plan is committed to protecting the privacy of your personal health information by complying with all applicable federal and state laws.
The following categories describe the different ways that the Plan uses and discloses your personal health information. Not every use or disclosure within a category is listed, but all uses and disclosures fall into one of the following categories.
Payment: The Plan may use and disclose personal health information about you for payment purposes, such as determining your eligibility for Plan benefits, determining benefit responsibility under the Plan, and coordinating benefits with other Plans. For example, the Plan may share personal health information with third party administrators hired to provide claims processing and other administrative services to the Plan.
Health Care Operations: The Plan may use and disclose personal health information about you for health care operations. These uses and disclosures are necessary to operate the Plan. For example, to conduct quality assessment and improvement activities, and for cost management and business management purposes.
Treatment: The Plan may use or disclose personal health information for treatment purposes, including facilitating medical services or treatment by your health care providers. For example, the Plan may disclose your personal health information to your physician if he/she asks the Plan for information to assist in your treatment.
Disclosures to St. Olaf College, the Plan Sponsor: The Plan may disclose your personal health information to St. Olaf College, which sponsors the Plan, to permit the company to perform plan administration functions. No personal health information with respect to the Employee Assistance Program will be disclosed to St. Olaf College without written authorization from the employee.
Disclosures to Other Plans: The Plan may disclose your personal health information to another health plan to facilitate claims payment under that plan and certain health care operations of that plan.
Individuals Involved in Your Care or Payment for Your Care: The Plan may disclose to your family members, friends, and persons you indicate are involved in your care or payment for your care, personal health information that is directly relevant to their involvement, unless you object. If you are unavailable or incapacitated, or in an emergency, the Plan may disclose your personal health information to these persons if it determines that the disclosure is in your best interest. The Plan also may use or disclose your name, location and general condition (or death) to notify persons involved in your care about your situation.
Communication about Benefits, Products and Services: The Plan may use your personal health information to contact you with information about benefits under the Plan. The Plan may use and disclose personal health information to tell you about or recommend possible treatment options or alternatives, or to tell you about health-related products or services (or payment or coverage for such products or services) that may be of interest to you. The Plan may communicate with you face-to-face regarding any products or services.
Other Permitted Purposes: The Plan may use and disclose your personal health information for the following purposes under limited circumstances:
- When required by law;
- For disaster relief efforts;
- For public health and safety (such as reporting disease outbreaks);
- For government oversight of the health care system (such as audits or investigations);
- For judicial and administrative proceedings (such as responding to a court order);
- For law enforcement purposes (such as providing information to help locate a missing person);
- For research purposes (subject to certain privacy requirements under state and federal law);
- To avoid a serious and imminent threat to health or safety;
- To create a collection of de-identified information that can no longer be traced back to you;
- Information about a deceased person, for certain limited purposes, to a coroner or medical examiner
- For purposes related to organ or tissue donation;
- For certain military and national security purposes;
- For workers’ compensation purposes.
Uses and Disclosures You Specifically Authorize: You may give the Plan written authorization to use your personal health information or to disclose it to anyone for any purpose. If you give the Plan an authorization, you may revoke it in writing at any time. If you revoke your permission, the Plan will stop using or disclosing your personal health information in accordance with that authorization, except to the extent the Plan has already relied on it. Without your written authorization, the Plan may not use or disclose your personal health information for any reason except those described in this notice.
Access: You have the right to look at or get copies of personal health information maintained by the Plan that may be used to make decisions about your Plan eligibility and benefits, with limited exceptions. The Plan reserves the right to require you to make this request in writing. You may be charged a fee for copies.
Amendment: If you feel that your personal health information is incorrect or incomplete, you have the right to request that the Plan amend it. The Plan reserves the right to require this request be in writing, including a reason to support your request. The Plan may deny your request if the Plan did not create the information you want amended or for certain other reasons.
Accounting of Disclosures: You have the right to receive a list of disclosures the Plan has made of your personal health information. This right does not apply to disclosures for treatment, payment, health care operations, and certain other purposes. You are entitled to such an accounting for the 6 years prior to your request, though not earlier than April 14, 2004. If you request this list more than once in a 12-month period, you may be charged a fee.
Restriction Requests: You have the right to request that the Plan place additional restrictions on its use or disclosure of your personal health information for treatment, payment, or health care operations. The Plan is not required to agree to these restrictions.
Confidential Communication: You have the right to request that the Plan communicate with you about your personal health information by alternative means or to an alternative location, if you would otherwise be endangered. The Plan will accommodate reasonable written requests.
Copy of this Notice: You are entitled to receive a printed copy of this notice at any time.
Exercising Your Rights: To obtain a copy of this notice, contact the Plan using the information listed at the end of this notice. To make a request regarding any of the other rights described in this section, or to obtain forms or information about fees, contact the administrator for the particular plan or benefit using the contact information provided to you by the administrator. If you have questions about how to contact the administrator, contact the Plan using the information listed at the end of this notice, and you will be directed to the appropriate administrator.
If you want more information about the Plan’s privacy practices, have questions or concerns, or believe that the Plan may have violated your privacy rights, please contact the Plan using the following information:
St. Olaf College
c/o Health Plan Privacy Officer
Human Resources Department
1520 St. Olaf Avenue
Northfield, MN 55057-1098
Telephone: (507) 786-3068
You also may submit a written complaint to the U.S. Department of Health and Human Services. The Plan will provide you with the address upon request.
The Plan supports your right to the privacy of your medical information. The Plan will not retaliate in any way if you choose to file a complaint with the Plan or with the U.S. Department of Health and Human Services.