| NOTICE OF PRIVACY PRACTICES |
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. NO ACTION IS REQUIRED ON YOUR PART. Effective April 14, 2003 At PacifiCare the protection of our members' privacy and the confidentiality of medical information has always been a priority. We recognize that you depend upon us to safeguard your personal information and uphold your privacy rights. This document-which is based on state and federal law, as well as our own company code of ethics-offers a declaration of our commitment to preserving member confidentiality and privacy. |
| This notice describes PacifiCare's privacy practices
for both current and former members. It explains how we use health
information about you and when we may share that health information
with others. It also informs you about your rights with respect to
your health information and how you may exercise these rights. We
are required by law to maintain the privacy of your health information
and to send you a copy of this notice so that you are aware of how
we maintain the privacy of your health information.
PacifiCare employees are required to comply with our policies and procedures to protect the confidentiality of health information. Any employee who violates our privacy policy is subject to a disciplinary process. Employee access to health information is limited on a business "need-to-know" basis, such as: to make benefit determinations, pay claims, manage care, underwrite coverage, perform quality assessment measurements, administer a plan or provide customer service. PacifiCare maintains physical, electronic and process safeguards that restrict unauthorized access to your health information. Such safeguards include secured office facilities, locked file cabinets, and controlled computer network sysTerms and password accounts. This notice applies to all applicable companies within the PacifiCare family of companies, which includes businesses owned or controlled by PacifiCare Health Systems, Inc. (PacifiCare). Please share this notice with everyone covered by your policy or contract. You have a right to receive a copy of this notice upon request at any time. If you would like additional copies of the notice, or have questions related to the information contained within the notice, please call Member/Customer Service at the toll-free number on your health plan identification card. You may also view a copy of this notice on our Web sites at www. PacifiCare.com and www.SecureHorizons.com. Should any of our privacy practices change, we reserve the right to change the terms of this notice and to make the new notice effective for all health information that we maintain. We will provide you a copy of the revised notice and post the revised notice on our Web sites. |
| When we refer to "information" or "health
information" in this notice, we mean information about you, including
demographic information, that may identify you and that relates to
your past, present or future physical or mental health and related
health care services. Health information may be transmitted or shared
in any form or medium (oral, written, or electronic).
The health information we receive may vary by product; therefore,
the examples that follow may not apply to all members, but are designed
to represent the general categories of information that may be received
and maintained by PacifiCare:
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| The following categories describe how we may use and share your health information. For each category we provide examples that help illustrate each type of use or disclosure. Not every use or disclosure in a category will be listed. However, the ways in which we are permitted to use and share health information will fall into one of these categories. |
| We may share health information with your doctors or hospitals to help them provide medical care for you. For example, if you are hospitalized, we may allow the hospital staff access to any medical records sent to us by your doctor. We may also use or share your health information with others to help coordinate and manage your health care. For example, we may talk to your doctor to suggest a disease management or wellness program that can help improve your health. |
| We may use your health information when paying your medical bills submitted to us by you or your health care providers, such as doctors and hospitals. Examples of payment activities include billing, claims management and other related administrative functions. |
We may use or share certain health information for
necessary health care operations. Examples of health care operations
include the following:
We may also share your health information with other individuals
or entities-also known as business associates-that perform payment
or health care operations on behalf of PacifiCare. However, we will
not share your health information with these business associates
unless they agree in writing to protect the privacy of that information. |
| We may use or share your health information with
a third party acting on behalf of PacifiCare in order to inform you
about alternative medical treatments and programs or about health-related
products and services that may be of value to you. We may also inform
you about enhancements, replacements or substitutions to your health
plan coverage.
[For members that reside in Oregon and Nevada,
if you do not want PacifiCare to share health information as described
above, you may "opt-out" by calling the Member/Customer
Service toll-free number on your health plan identification card
during normal business hours.] |
| We may use or share your health information when
it has been "de-identified." Health information is considered
to be de-identified when it does not personally identify you.
We may also use a "limited data set" that does not contain
any information that can directly identify you. This limited data
set may only be used for the purposes of research, public health
matters or health care operations. For example, a limited data set
may include your city, county and zip code, but not your name or
street address. |
| Under certain circumstances, we may share limited
health information about you with the employee benefit plan through
which you receive health benefits. For example, we may share summary
health information with the employee benefit plan so that they may
obtain bids from other health plans, or modify, amend, or terminate
coverage with PacifiCare. We may also share health information related
to your enrollment, disenrollment and/or participation in a PacifiCare
health plan. We will not share detailed health information with your
benefit plan unless they agree to maintain the privacy of your information.
[For members that reside in California and
Oklahoma, PacifiCare may not share your health information with
your employer or benefit plan unless you provide written permission
for us to do so]. |
Special situations and certain state and federal
laws may require us to use or release your health information. For
example, we may be obligated to release your health information for
the following reasons:
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| For any other activity or purpose not listed above or as otherwise permitted by law we must obtain your written permission-known as an authorization-prior to using or sharing your health information. If you provide a written authorization and you change your mind, you may revoke your authorization in writing at any time. Once an authorization has been revoked, we will no longer use or share the health information as outlined in the authorization form; however, you should be aware that we may not be able to retract a use or disclosure that was previously made based on a valid authorization. |
Depending on the state in which you reside, there may be additional laws related to the use and disclosure of health information related to HIV status, communicable diseases, reproductive health, genetic test results, substance abuse, mental health and mental retardation. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The following are your rights with respect to your health information. If you would like to exercise the following rights, please call Member/Customer Service at the toll-free number on your health plan identification card. You have the right to ask us to restrict how we use or
share your health information for treatment, payment or health care
operations. You also have the right to ask us to restrict
health information that we have been asked to give to family members
or to others who are involved in your health care or payment for
your health care. Please note that while we will try to honor your
requests, we are not required by law to agree to the type of restrictions
described above. This right does not obligate us to grant you access to certain
types of health information. Please note that under most circumstances
we will not provide you with copies of the following information:
If you request a copy of your designated record set, a fee for the costs of copying, mailing or other associated supplies may be charged. Additionally, under certain circumstances we may deny your request to inspect or obtain a copy of your health information. If we deny your request, we will notify you in writing and may provide you the option to have the denial reviewed. If you would like to request access to review or copy your patient medical records, please directly contact your Primary Care Physician or the health care provider who created the records. Patient medical records include records in any form or medium maintained by, or in the custody or control of, a health care provider relating to health history, diagnosis, or condition of a patient, or relating to treatment provided or proposed to be provided to the patient. You have the right to ask us to make changes to the health information that we maintain about you in your designated record set. These changes are referred to as amendments. We may require that your request be in writing and that you provide a reason for your request. If we make the amendment, we will notify you that it was made. If we deny your request to amend, we will notify you in writing of the reason for denial. This written notification will explain your right to file a written statement of disagreement. In return, we have a right to rebut your statement. Furthermore, you have the right to request that your initial written request, our written denial and your statement of disagreement be included with your health information for any future disclosures. You have the right to receive an accounting of certain disclosures of your health information made by us during the six years prior to your request. We may require that your request for an accounting be in writing. Your first accounting is free. Subsequently, you are allowed one free accounting upon request every 12 months. If you request an additional accounting within 12 months of receiving your free accounting, we may charge you a fee. We will inform you in advance of the fee and provide you with an opportunity to withdraw or modify your request. Please note that, under most circumstances, we are not required
to provide you with an accounting of disclosures of the following
information:
QUESTIONS REGARDING USE AND DISCLOSURE AND YOUR PRIVACY
RIGHTS |
| If you believe that your privacy rights have been
violated, you may file a complaint with us by calling PacifiCare's
Privacy Line at 1-800-481-6982. You may also direct your complaints
to the Secretary of the U.S. Department of Health and Human Services.
PacifiCare will not penalize you or take any action against you for filing a complaint. How to Obtain More Information Regarding Your Rights as
well as the Use and Disclosure of Your Health Information |
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