PA13_05_GN Notice Of Privacy

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User Manual: PrivacyNotice

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NOTICE OF PRIVACY PRACTICES
IMPORTANT INFORMATION ABOUT YOUR PRIVACY RIGHTS
Effective November 15, 2007
Revised: August 2013
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, AND SHARE IT WITH YOUR SPOUSE AND OTHER DEPENDENTS WHO ARE
COVERED UNDER GUILDNET MANAGED LONG TERM CARE, GUIILDNET GOLD, GUILDNET
GOLD PLUS AND GUILDNET HEALTH ADVANTAGE (“PLAN”).
THIS NOTICE APPLIES TO THE OFFICES OF THE PLAN AND TO THE SERVICES THAT THE PLAN
PROVIDES THROUGH BUSINESS ASSOCIATES OF THE PLAN.
INTRODUCTION
During the course of providing you with health coverage, the Plan will have access to information about you
that has been deemed to be “Protected Health Information” (PHI) by the Health Insurance Portability and
Accountability Act of 1996, commonly known as “HIPAA.” This Notice describes the medical information
privacy practices of the Plan, and explains our obligations and your rights regarding the use and disclosure of
your protected health information. This Notice also applies to other business associates that assist in the
administration of the Plan.
If you have any questions about this Notice, please contact the Plan’s Privacy Officer at the address and phone
number listed at the end of this Notice.
OUR PLEDGE REGARDING MEDICAL INFORMATION
We understand that medical information about you and your health is personal information. We are committed
to protecting your medical information. Under HIPAA, your protected health information includes any
individually identifiable information that relates to your past, present or future physical or mental health, the
health care that you have received or payment for your health care, including your name, address, date of birth
and Social Security number. This Notice covers any such PHI that is maintained by the Plan. Your personal
physician or health care provider may have different policies or notices regarding their use and disclosure of
your PHI.
We are required by law to:
Ø Make sure that your PHI is kept private;

Ø Provide you with this Notice of our legal duties and privacy practices with respect to your PHI;
Ø Notify affected individuals following a breach of unsecured PHI; and
Ø Follow the terms of the Notice (as currently in effect or subsequently amended).
HOW WE MAY USE AND DISCLOSE YOUR PHI
I.

Uses and Disclosures for Treatment, Payment and Health Care Operations

The Plan may use or disclose your PHI in connection with your receiving treatment from a health care provider,
our payment for such treatment and for our health care operations. The Plan will make reasonable efforts not to
disclose more than the minimum necessary amount of PHI to achieve the particular purpose of the disclosure.
For Treatment: Although the Plan does not provide treatment, we may use or disclose your PHI to support the
provision, coordination or management of your health care treatment. This includes that we may disclose your
PHI to your health care providers, including doctors, nurses, technicians or other hospital personnel who are
involved in taking care of you. For example, if in the event of an emergency, you are unable to give your
doctor your medical history, the Plan may share that history (if known to the Plan) with an emergency room
physician so that the physician can most appropriately provide medical services to you.
For Payment: “Payment” generally means activities in connection with processing claims for your health care
(including billing, claims management, subrogation, reviews for medical necessity and appropriateness of care
and utilization review and preauthorization’s). We may use or disclose your PHI for payment purposes, such as
to determine your eligibility for Plan benefits, to facilitate the payment for treatment or services you receive
from your health care providers, to determine benefit responsibility under the Plan, or to coordinate your Plan
coverage with another health plan. For example, we may disclose your PHI to your health care provider to
determine whether a particular treatment is medically necessary, or to determine whether the Plan will cover the
treatment. We may also share PHI with a utilization review or precertification service provider. Additionally,
we may share PHI with another entity to assist in the adjudication or subrogation of claims.
For Health Care Operations: We may use or disclose your PHI as part of the general administrative or
business functions of the Plan that we must perform in order to function as a health plan. For example, we may
need to review your PHI as part of the Plan’s efforts to uncover instances of health care provider fraud, waste
and abuse. Additionally, we may use your PHI in connection with: conducting quality assessment and
improvement activities and other activities relating to Plan coverage, submitting claims for stop-loss (or excess
loss) coverage, conducting or arranging for medical review, legal services, or audit services.
Disclosure to Third Parties: In any circumstance where we disclose PHI to a third party that performs a
service on behalf of the Plan (i.e., a Business Associate), we will have a written contract with that entity which
requires the entity to also protect the privacy of your PHI.
II.

Disclosures to Your Representatives

Individuals Involved in Your Care or Payment For Your Care: Unless you object in writing, the Plan may
disclose PHI to a close friend or family member involved in or who helps pay for your health care, but only to
the extent relevant to that friend or family member’s involvement in your care or payment for your care. For
example, if a family member or a caregiver calls the Plan with prior knowledge of a claim, the Plan may
confirm whether or not the claim has been received and paid. We may also disclose your PHI to any authorized
public or private entities assisting in disaster relief efforts.
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Disclosure to Your Personal Representatives: We may disclose your PHI to your personal representative in
accordance with applicable state law and HIPAA. In addition, you may authorize a personal representative to
receive your PHI and act on your behalf. Contact the Privacy Officer to obtain a copy of the appropriate form
to authorize the people who may receive this information.
III.

Other Permitted Uses and Disclosures

The Plan may also use or disclose your PHI for any of the following purposes:
Required By Law: We may use or disclose your PHI to the extent that we are required to do so by federal,
state or local law. You will be notified, if required by law, of any such uses or disclosures.
Public Health: We may disclose your PHI for public health and safety purposes to a public health authority
that is permitted by law to collect or receive the information. Your PHI may be used or disclosed for the
purpose of preventing or controlling disease (including communicable diseases), injury or disability. If directed
by the public health authority, we may also disclose your PHI to a foreign government agency that is
collaborating with the public health authority.
Health Oversight: We may disclose your PHI to a health oversight agency for activities authorized by law,
such as audits, investigations, inspections and legal actions. Oversight agencies seeking this information
include government agencies that oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your PHI to any public health authority authorized by law to receive
information about abuse, neglect or domestic violence if we reasonably believe that you have been a victim of
abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements
of applicable federal and state laws, and we will inform you that such a disclosure has been or will be made
unless that notice will cause a risk of serious harm.
To Avert A Serious Threat to Health or Safety: We may use or disclose your PHI 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 reasonably able to help prevent or lessen the threat.
Legal Proceedings: We may disclose your PHI in the course of any judicial or administrative proceeding, in
response to an order of a court or administrative tribunal. In addition, we may disclose your PHI under certain
conditions in response to a subpoena, court-ordered discovery request or other lawful process, in which case
reasonable efforts must be undertaken by the party seeking the PHI to notify you and give you an opportunity to
object to the disclosure.
Law Enforcement: We may disclose your PHI if requested by a law enforcement official as part of certain law
enforcement activities.
Coroners, Funeral Directors, and Organ Donation: We may disclose your PHI to a coroner or medical
examiner for identification purposes, or other duties authorized by law. We may also disclose your PHI to a
funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. We may
disclose such information in reasonable anticipation of death. We may also disclose PHI for cadaveric organ,
eye or tissue donation purposes.

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Research: We are permitted to disclose your PHI to researchers when their research has been approved by an
institutional review board that has established protocols to ensure the privacy of your PHI.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI
of individuals who are Armed Forces personnel: (1) for activities deemed necessary by military command
authorities; or (2) to a foreign military authority if you are a member of that foreign military service. We may
also disclose your PHI to authorized federal officials conducting national security and intelligence activities.
Workers’ Compensation: We may disclose your PHI to comply with workers’ compensation laws and other
similar legally established programs.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official,
we may disclose your PHI to the institution or official if the PHI is necessary for the institution to provide you
with health care; to protect the health and safety of you or others; or for the security of the correctional
institution.
Required Uses and Disclosures: We must make disclosures of PHI to the Secretary of the U.S. Department of
Health and Human Services (“HHS”) to investigate or determine our compliance with the federal regulations
regarding privacy.
USES AND DISCLOSURES OF PHI THAT REQUIRE YOUR WRITTEN AUTHORIZATION
The Plan will not use or disclosure your PHI for the following purposes without your prior written
authorization:
Psychotherapy Notes: Except for certain narrow exceptions permitted by law (such as legal defense in a
proceeding you bring against us), we will not use or disclose any mental health professionals psychotherapy
notes (discrete notes that document the contents of conversations during counseling sessions) without your prior
written authorization.
Marketing or Sales: Unless you give us your prior written authorization, we will not use or disclose your PHI
for any paid marketing activities or sell your PHI.
Other Uses and Disclosures of PHI: Other uses and disclosures of your PHI not described in this Notice will
only be made with your prior written authorization. If you provide us with written authorization to use or
disclose your PHI for purposes other than those set forth in this Notice, you may revoke that authorization in
writing at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the
reasons covered by your written authorization. However, you understand that we are unable to take back any
disclosures we have already made with your authorization, and that we are required to retain records of the
services we provide to you.
NO USE OR DISCLOSURE OF GENETIC INFORMATION FOR UNDERWRITING
The Plan is prohibited by law from using or disclosing PHI that is genetic information of an individual for
underwriting purposes. Generally, genetic information involves information about differences in a person’s
DNA that could increase or decrease his or her chance of getting a disease (for example, diabetes, heart disease,
cancer or Alzheimer's disease).

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ADDITIONAL SPECIAL PROTECTIONS
Additional special privacy protections, under federal or state law, may apply to certain sensitive information,
such as genetic information, HIV-related information, alcohol and substance abuse treatment information, and
mental health information. If you have questions please contact our Privacy Officer at the address below.
YOUR RIGHTS
You have the following rights regarding the PHI that we maintain:
Right to Inspect and Copy: As long as we maintain it, you may inspect and obtain a copy of your PHI that is
contained in a “designated record set” – which are records used in making enrollment, payment, claims
adjudication, medical management and other decisions. To request access to inspect and/or obtain a copy of
any of your PHI, you must submit your request in writing to our Privacy Officer at the address below indicating
the specific information requested, and you may also direct us to transmit the copy of PHI directly to another
person that you designate in writing. If you request a copy of PHI, please indicate in which form you want to
receive it (i.e., paper or electronic). We may impose a fee to cover the costs of producing, copying and mailing
the requested PHI.
We may deny your request to inspect and copy your PHI in certain limited circumstances. For example, under
federal law, you may not inspect or copy psychotherapy notes or information compiled in reasonable
anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. If access is denied, you or
your personal representative will be provided with a written denial setting forth the basis for the denial, a
description of how you may exercise your review rights and a description of how you may complain to the Plan
and to HHS.
Right to Request a Restriction on the Use and Disclosure of Your PHI: You may ask us to restrict the uses
and disclosures of your PHI to carry out treatment, payment or health care operations. You may also request
that we restrict uses and disclosures of your PHI to family members, relatives, friends or other persons
identified by you who are involved in your care.
However, we are not required to agree to a restriction that you request. If we do agree to the request, we will
not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment or
we terminate the restriction with or without your agreement. If you do not agree to the termination, the
restriction will continue to apply to PHI created or received prior to our notice to you of our termination of the
restriction.
To request a restriction, you must write to our Privacy Officer at the address below indicating (1) what
information you want to restrict, (2) whether you want to restrict use, disclosure or both, and (3) to whom you
want the restriction to apply.
Right to Request to Receive Confidential Communications by Alternative Means or at an Alternative
Location: We will accommodate your reasonable request to receive communications of PHI from us by
alternative means or at alternative locations if the request includes a statement that disclosure using the Plan’s
regular communications procedures could endanger you. Please direct your written request to our Privacy
Officer at the address below.
Right to Amend Your PHI: If you believe that PHI that we have about you is incorrect or incomplete, you
may request that it be amended. Your request must be made in writing and submitted to our Privacy Officer. In
addition, you must provide a reason that supports your request.
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We 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, we may deny your request if you ask us to amend information that:
Ø Did not originate with us, unless the person or entity that originated the PHI is no longer available to
make the amendment;
Ø Is not contained in the records maintained by the Plan;
Ø Is not part of the information that you would legally be permitted to inspect and copy;
Ø Is accurate and complete.
Right to an Accounting of Disclosures: You have the right to request an accounting (i.e., a list) of certain
non-routine disclosures of your PHI. In general, the list will not include disclosures that were made:
Ø In connection with your receiving treatment, our payment for such treatment and for health care
operations;
Ø To you regarding your own PHI;
Ø Pursuant to your written authorization;
Ø To a person involved in your care or for other permitted notification purposes;
Ø For national security or intelligence purposes; or
Ø To correctional institutions or law enforcement officials.
To request a list of disclosures, contact our Privacy Officer at the address below. You have the right to receive
an accounting of disclosures of PHI made within six years (or less) of the date on which the accounting is
requested. Your request should indicate the form in which you want the list (e.g., paper or electronic). The first
accounting you request within a 12-month period will be free of charge. For additional requests within the 12month period, we will charge you for the costs of providing the accounting. We will notify you of the cost
involved and you may choose to withdraw or modify your request at that time before any cost is incurred.
We will act on your request for an accounting no later than 60 days after receipt of your request. This time
period may be extended, where necessary, for an additional 30 days. If this should happen, you will be notified
in writing concerning the reasons for the delay and the date by which we will provide the accounting.
Right to Obtain a Paper Copy of this Notice: You may request a paper copy of our Privacy Notice at any
time, even if you have previously agreed to accept the Notice electronically. Requests should be made to the
Privacy Officer at the address below.
COMPLAINTS
If you believe that your privacy rights have been violated, you may file a written complaint with us at the
address below or with the Secretary of the U.S. Department of Health and Human Services, Hubert H.
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Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. 20201. We will not retaliate against
you for filing a complaint.

CHANGES TO THIS NOTICE
We reserve the right to change the terms of this or any subsequent Notice at any time. If we elect to make a
change, the revised Notice will be effective for all PHI that we maintain at that time. This Notice is posted on
our website. If we make a material change to this Notice we will post the revised Notice by the effective date of
the material change along with providing information about the change and how to obtain the revised Notice in
our next annual mailing to members. If we do not post this Notice on our website we will provide information
about the material change and how to obtain the revised Notice to members within 60 days of the change.
FOR QUESTIONS OR REQUESTS
If you have any questions regarding this Notice or the subjects addressed in it, or would like to submit a request
as described above, please contact:
Privacy Officer
Jewish Guild Healthcare
15 West 65th Street
New York, New York 10023
212-769-6212

PA13_05_GN Notice of Privacy
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