Fillable SISC Enrollment Form

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SISC Enrollment Form

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SECTI
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ENROLLMENT REASON: □ NEW HIRE □OPEN ENROLLMENT □ EMPLOYEE STATUS CHANGE □ LOSS OF COVERAGE □COBRA
QUALIFYING
DATE:
EFFECTIVE
DATE:
HIRE
DATE:
DISTRICT
APPROVED
INITIALS:
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If you are retired and entitled to Medicare and not enrolled, you may be subject to a premium surcharge.
Are you retired? □ YES □ NO
If yes, do you have Medicare? □ YES □ NO
(Copy of Medicare card required)
TOTALLY DISABLED?
□
YES
□
NO
Do any of your dependents have Medicare? □ YES □ NO
(Copy of Medicare card required)
SEC
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Proof of eligibility required (i.e. birth/marriage/domestic partner certificate)
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Gender
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LAST NAME (PRINT) FIRST NAME (PRINT) MI SOCIAL SECURITY NO.
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LAST NAME (PRINT) FIRST NAME (PRINT) MI SOCIAL SECURITY NO.
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SISC III ENROLLMENT FORM
–
(DO NOT use for Kaiser members, use Kaiser Permanente enrollment form for Kaiser members)
(Type or print clearly in black ink)
•
I understand it is my responsibility to notify my district once a dependent is no longer eligible due to divorce or over age children. If I fail to report loss of eligibility I may be financially liable
to SISC if claims were paid on behalf of non-eligible individuals.
•
DEDUCTION AUTHORIZATION: If applicable, I authorize my school district to deduct from my wages the required contribution.
•
NON-PARTICIPATING PROVIDER: I understand that I am responsible for a greater portion of my medical costs when I use a non-participating provider.
•
HIV Testing Prohibited: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance.
•
EFFECTIVE DATE: The effective date of coverage is subject to SISC III approval.
•
Any complaints regarding the exemption due to the Knox-Keene Health Care Service Plan Act of 1975 may be directed to the Department of Managed Health Care of the State of California.
SECTION IV: SIGNATURE OF UNDERSTANDING – APPLICANT MUST SIGN
I have read and understood the provisions outlined on this form. All information on this form is correct and true. I understand that it is the basis on which coverage may be issued under the plan.
Any misstatements or omissions may result in future claims being denied and/or the policy being rescinded. You are entitled to a copy of this signed authorization for your files. Additionally, any
person who knowingly and with intent to injure, defraud, or deceive the district, SISC, or plan service provider, by filing a statement or claim containing false or misleading information may be guilty
of
a criminal act punishable under law. I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief; it is true and accurate with
no omissions or misstatements.
ARBITRATION AGREEMENT: I UNDERSTAND THAT ANY AND ALL DISPUTES BETWEEN MYSELF (AND/OR ANY ENROLLED FAMILY
MEMBER) AND SISC III (INCLUDING CLAIMS ADMINISTRATOR OR AFFILIATE) INCLUDING CLAIMS FOR MEDICAL MALPRACTICE, MUST
BE RESOLVED BY BINDING ARBITRATION, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF THE SMALL CLAIMS
COURT, AND NOT BY LAWSUIT OR RESORT TO COURT PROCESS, EXCEPT AS CALIFORNIA LAW PROVIDES FOR JUDICIAL REVIEW OF
ARBITRATION PROCEEDINGS. UNDER THIS COVERAGE, BOTH THE MEMBER AND SISC III ARE GIVING UP THE RIGHT TO HAVE ANY
DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY. SISC III AND THE MEMBER ALSO AGREE TO GIVE UP ANY RIGHT TO PURSUE
ON A CLASS BASIS ANY CLAIM OR CONTROVERSY AGAINST THE OTHER. (FOR MORE INFORMATION REGARDING BINDING
ARBITRATION, PLEASE REFER TO YOUR EVIDENCE OF COVERAGE BOOKLET.)
Applicant Signature Required Date
http://sisc.kern.org/hw
Rev 2015 Jan
1
Self-Insured Schools of California (SISC)
HIPAA Notice of Privacy Practices
Esta noticia es disponible en espanol si usted lo suplica. Por favor contacte el oficial de privacidad indicado a continuación.
Purpose of This Notice
This Notice describes how medical information about you may be
used and disclosed and how you may get access to this information.
Please review this information carefully.
This Notice is required by law.
The Self-Insured Schools of California (SISC) group health plan consisting of these self-funded benefits: medical PPO plan
options including utilization management, prescription benefit management (PBM) and medical plan claims administration
services, telemedicine program with MDLIVE, self-funded dental PPO plan options, self-funded vision PPO plan options,
Wellness program, Medicare Supplement program, COBRA administration, and Health Flexible Spending Account (FSA)
administration, (hereafter referred to as the “Plan”), is required by law to take reasonable steps to maintain the privacy of
your personally identifiable health information (called Protected Health Information or PHI) and to inform you about the
Plan’s legal duties and privacy practices with respect to protected health information including:
1. The Plan’s uses and disclosures of PHI,
2. Your rights to privacy with respect to your PHI,
3. The Plan’s duties with respect to your PHI,
4. Your right to file a complaint with the Plan and with the Secretary of the U.S. Department of Health and Human
Services (HHS), and
5. The person or office you should contact for further information about the Plan’s privacy practices.
6. To notify affected individuals following a breach of unsecured protected health information.
PHI use and disclosure by the Plan is regulated by the Federal law, Health Insurance Portability and Accountability Act,
commonly called HIPAA. You may find these rules in 45 Code of Federal Regulations Parts 160 and 164. This Notice
attempts to summarize key points in the regulation. The regulations will supersede this Notice if there is any discrepancy
between the information in this Notice and the regulations. The Plan will abide by the terms of the Notice currently in effect.
The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI it
maintains.
You may receive a Privacy Notice from a variety of the insured group health benefit plans offered by SISC. Each of these
notices will describe your rights as it pertains to that plan and in compliance with the Federal regulation, HIPAA. This
Privacy Notice however, pertains to your protected health information held by the SISC self-funded group health plan (the
“Plan”) and outside companies contracted with SISC to help administer Plan benefits, also called “business associates.”
Effective Date
The effective date of this Notice is June 24, 2013, and this notice replaces notices previously distributed to you.
Privacy Officer
The Plan has designated a Privacy Officer to oversee the administration of privacy by the Plan and to receive complaints.
The Privacy Officer may be contacted at:
Privacy Officer: Coordinator Health Benefits
Self-Insured Schools of California (SISC)
2000 “K” Street P.O. Box 1847 - Bakersfield, CA 93303-1847
Phone: 661-636-4410
Confidential Fax: 661-636-4893
2
Your Protected Health Information
The term “Protected Health Information” (PHI) includes all information related to your past, present or future health
condition(s) that individually identifies you or could reasonably be used to identify you and is transferred to another entity or
maintained by the Plan in oral, written, electronic or any other form.
PHI does not include health information contained in employment records held by your employer in its role as an employer,
including but not limited to health information on disability, work-related illness/injury, sick leave, Family or Medical Leave
(FMLA), life insurance, dependent care flexible spending account, drug testing, etc.
This Notice does not apply to information that has been de-identified. De-identified information is information that does not
identify you, and with respect to which there is no reasonable basis to believe that the information can be used to identify
you, is not individually identifiable health information.
When the Plan May Disclose Your PHI
Under the law, the Plan may disclose your PHI without your written authorization in the following cases:
• At your request. If you request it, the Plan is required to give you access to your PHI in order to inspect it and copy it.
• As required by an agency of the government. The Secretary of the Department of Health and Human Services may
require the disclosure of your PHI to investigate or determine the Plan’s compliance with the privacy regulations.
• For treatment, payment or health care operations. The Plan and its business associates will use your PHI (except
psychotherapy notes in certain instances as described below) without your consent, authorization or opportunity to agree
or object in order to carry out treatment, payment, or health care operations.
The Plan does not need your consent or authorization to release your PHI when you request it, a government agency requires
it, or the Plan uses it for treatment, payment or health care operations.
The Plan Sponsor has amended its Plan documents to protect your PHI as required by Federal law. The Plan may disclose
PHI to the Plan Sponsor for purposes of treatment, payment and health care operations in accordance with the Plan
amendment. The Plan may disclose PHI to the Plan Sponsor for review of your appeal of a benefit or for other reasons
related to the administration of the Plan.
Definitions and Examples of Treatment, Payment and Health Care Operations
Treatment is
health care.
Treatment is the provision, coordination or management of health care and related services. It also
includes but is not limited to coordination of benefits with a third party and consultations and
referrals between one or more of your health care providers.
• For example:
The Plan discloses to a treating specialist the name of your treating primary
care physician so the two can confer regarding your treatment plan.
Payment is
paying claims for
health care and
related activities.
Payment includes but is not limited to making payment for the provision of health care,
determination of eligibility, claims management, and utilization review activities such as the
assessment of medical necessity and appropriateness of care.
• For example:
The Plan tells your doctor whether you are eligible for coverage or what
percentage of the bill will be paid by the Plan. If we contract with third parties to help us
with payment, such as a claims payer, we will disclose pertinent information to them. These
third parties are known as “business associates.”
Health Care
Operations keep
the Plan operating
soundly.
Health care operations includes but is not limited to quality assessment and improvement, patient
safety activities, business planning and development, reviewing competence or qualifications of
health care professionals, underwriting, enrollment, premium rating and other insurance activities
relating to creating or renewing insurance contracts. It also includ
es disease management, case
management, conducting or arranging for medical review, legal services and auditing functions
including fraud and abuse compliance programs and general administrative activities.
• For example: The Plan uses information about your medical claims to refer you to a disease
management program, to project future benefit costs or to audit the accuracy of its claims
processing functions.
When the Disclosure of Your PHI Requires Your Written Authorization
Generally, the Plan will require that you sign a valid authorization form in order to use or disclose your PHI other than:
• When you request your own PHI
• A government agency requires it, or
3
• The Plan uses it for treatment, payment or health care operation.
You have the right to revoke an authorization.
Although the Plan does not routinely obtain psychotherapy notes, generally, an authorization will be required by the Plan
before the Plan will use or disclose psychotherapy notes about you. Psychotherapy notes are separately filed notes about
your conversations with your mental health professional during a counseling session. They do not include summary
information about your mental health treatment. However, the Plan may use and disclose such notes when needed by the
Plan to defend itself against litigation filed by you.
The Plan generally will require an authorization form for uses and disclosure of your PHI for marketing purposes (a
communication that encourages you to purchase or use a product or service) if the Plan receives direct or indirect financial
remuneration (payment) from the entity whose product or service is being marketed. The Plan generally will require an
authorization form for the sale of protected health information if the Plan receives direct or indirect financial remuneration
(payment) from the entity to whom the PHI is sold. The Plan does not intend to engage in fundraising activities.
Use or Disclosure of Your PHI Where You Will Be Given an Opportunity to Agree
or Disagree Before the Use or Release
Disclosure of your PHI to family members, other relatives and your close personal friends without your written consent or
authorization is allowed if:
• The information is directly relevant to the family or friend’s involvement with your care or payment for that care, and
• You have either agreed to the disclosure or have been given an opportunity to object and have not objected.
Note that PHI obtained by the Plan Sponsor’s employees through Plan administration activities will NOT be used for
employment related decisions.
Use or Disclosure of Your PHI Where Consent, Authorization or Opportunity to
Object Is Not Required
In general, the Plan does not need your written authorization to release your PHI if required by law or for public health and
safety purposes. The Plan and its Business Associates are allowed to use and disclose your PHI without your written
authorization (in compliance with section 164.512) under the following circumstances:
1. When required by law.
2. When permitted for purposes of public health activities. This includes reporting product defects, permitting product
recalls and conducting post-marketing surveillance. PHI may also be used or disclosed if you have been exposed to a
communicable disease or are at risk of spreading a disease or condition, if authorized by law.
3. To a school about an individual who is a student or prospective student of the school if the protected health information
this is disclosed is limited to proof of immunization, the school is required by State or other law to have such proof of
immunization prior to admitting the individual and the covered entity obtains and documents the agreements to this
disclosure from either a parent, guardian or other person acting in loco parentis of the individual, if the individual is an
unemancipated minor; or the individual, if the individual is an adult or emancipated.
4. When authorized by law to report information about abuse, neglect or domestic violence to public authorities if a
reasonable belief exists that you may be a victim of abuse, neglect or domestic violence. In such case, the Plan will
promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious
harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure
has been or will be made. Disclosure may generally be made to the minor’s parents or other representatives, although
there may be circumstances under Federal or state law when the parents or other representatives may not be given access
to the minor’s PHI.
5. To a public health oversight agency for oversight activities authorized by law. These activities include civil,
administrative or criminal investigations, inspections, licensure or disciplinary actions (for example, to investigate
complaints against providers) and other activities necessary for appropriate oversight of government benefit programs
(for example, to investigate Medicare or Medicaid fraud).
6. When required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a
subpoena or discovery request, provided certain conditions are met, including that:
• the requesting party must give the Plan satisfactory assurances a good faith attempt has been made to provide you
with written Notice, and
4
• the Notice provided sufficient information about the proceeding to permit you to raise an objection, and
• no objections were raised or were resolved in favor of disclosure by the court or tribunal.
7. When required for law enforcement health purposes (for example, to report certain types of wounds).
8. For law enforcement purposes if the law enforcement official represents that the information is not intended to be used
against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to
obtain the individual’s agreement and the Plan in its best judgment determines that disclosure is in the best interest of the
individual. Law enforcement purposes include:
• identifying or locating a suspect, fugitive, material witness or missing person, and
• disclosing information about an individual who is or is suspected to be a victim of a crime.
9. When required to be given to a coroner or medical examiner to identify a deceased person, determine a cause of death
or other authorized duties. When required to be given to funeral directors to carry out their duties with respect to the
decedent; for use and disclosures for cadaveric organ, eye or tissue donation purposes.
10. For research, subject to certain conditions.
11. When, consistent with applicable law and standards of ethical conduct, the Plan in good faith believes the use or
disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the
public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat.
12. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs
established by law.
13. When required, for specialized government functions, to military authorities under certain circumstances, or to
authorized Federal officials for lawful intelligence, counter intelligence and other national security activities.
Any other Plan uses and disclosures not described in this Notice will be made only if you provide the Plan with written
authorization, subject to your right to revoke your authorization, and information used and disclosed will be made in
compliance with the minimum necessary standards of the regulation.
Your Individual Privacy Rights
A. You May Request Restrictions on PHI Uses and Disclosures
You may request the Plan to restrict the uses and disclosures of your PHI:
• To carry out treatment, payment or health care operations, or
• To family members, relatives, friends or other persons identified by you who are involved in your care.
The Plan, however, is not required to agree to your request if the Plan Administrator or Privacy Officer determines it to
be unreasonable, for example, if it would interfere with the Plan’s ability to pay a claim.
The Plan will accommodate an individual’s reasonable request to receive communications of PHI by alternative means
or at alternative locations where the request includes a statement that disclosure could endanger the individual. You or
your personal representative will be required to complete a form to request restrictions on the uses and disclosures of
your PHI. To make such a request contact the Privacy Officer at their address listed on the first page of this Notice.
B. You May Inspect and Copy Your PHI
You have the right to inspect and obtain a copy (in hard copy or electronic form) of your PHI (except psychotherapy
notes and information compiled in reasonable contemplation of an administrative action or proceeding) contained in a
“designated record set,” for as long as the Plan maintains the PHI. You may request your hard copy or electronic
information in a format that is convenient for you, and the Plan will honor that request to the extent possible. You may
also request a summary of your PHI.
A Designated Record Set includes your medical records and billing records that are maintained by or for a covered
health care provider. Records include enrollment, payment, billing, claims adjudication and case or medical management
record systems maintained by or for a health plan or other information used in whole or in part by or for the covered
entity to make decisions about you. Information used for quality control or peer review analyses and not used to make
decisions about you is not included in the designated record set.
The Plan must provide the requested information within 30 days of its receipt of the request, if the information is
maintained onsite or within 60 days if the information is maintained offsite. A single 30-day extension is allowed if the
Plan is unable to comply with the deadline and notifies you in writing in advance of the reasons for the delay and the
date by which the Plan will provide the requested information.
5
You or your personal representative will be required to complete a form to request access to the PHI in your Designated
Record Set. Requests for access to your PHI should be made to the Plan’s Privacy Officer at their address listed on the
first page of this Notice. You may be charged a reasonable cost-based fee for creating or copying the PHI or preparing a
summary of your PHI.
If access is denied, you or your personal representative will be provided with a written denial describing the basis for the
denial, a description of how you may exercise those review rights and a description of how you may complain to the
Plan’s Privacy Officer or the Secretary of the U.S. Department of Health and Human Services.
C. You Have the Right to Amend Your PHI
You or your Personal Representative have the right to request that the Plan amend your PHI or a record about you in a
designated record set for as long as the PHI is maintained in the designated record set. The Plan has 60 days after
receiving your request to act on it. The Plan is allowed a single 30-day extension if the Plan is unable to comply with the
60-day deadline (provided that the Plan notifies you in writing in advance of the reasons for the delay and the date by
which the Plan will provide the requested information).
If the Plan denied your request in whole or part, the Plan must provide you with a written denial that explains the basis
for the decision. You or your personal representative may then submit a written statement disagreeing with the denial
and have that statement included with any future disclosures of your PHI. You should make your request to amend PHI
to the Privacy Officer at their address listed on the first page of this Notice.
You or your personal representative may be required to complete a form to request amendment of your PHI. Forms are
available from the Privacy Officer at their address listed on the first page of this Notice.
D. You Have the Right to Receive an Accounting of the Plan’s PHI Disclosures
At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI during the six
years (or shorter period if requested) before the date of your request. The Plan will not provide you with an accounting
of disclosures related to treatment, payment, or health care operations, or disclosures made to you or authorized by you
in writing. The Plan has 60 days after its receipt of your request to provide the accounting. The Plan is allowed an
additional 30 days if the Plan gives you a written statement of the reasons for the delay and the date by which the
accounting will be provided. If you request more than one accounting within a 12-month period, the Plan will charge a
reasonable, cost-based fee for each subsequent accounting.
E. You have the Right to Request that PHI be Transmitted to You Confidentially
The Plan will permit and accommodate your reasonable request to have PHI sent to you by alternative means or to an
alternative location (such as mailing PHI to a different address or allowing you to personally pick up the PHI that would
otherwise be mailed), if you provide a written request to the Plan that the disclosure of PHI to your usual location could
endanger you. If you believe you have this situation, you should contact the Plan’s Privacy Officer to discuss your
request for confidential PHI transmission.
F. You Have the Right to Receive a Paper or Electronic Copy of This Notice Upon Request
To obtain a paper or electronic copy of this Notice, contact the Plan’s Privacy Officer at their address listed on the first
page of this Notice. This right applies even if you have agreed to receive the Notice electronically.
G. Breach Notification
If a breach of your unsecured protected health information occurs, the Plan will notify you.
Your Personal Representative
You may exercise your rights to your protected health information (PHI) by designating a person to act as your Personal
Representative. Your Personal Representative will generally be required to produce evidence (proof) of the authority to act
on your behalf before the Personal Representative will be given access to your PHI or be allowed to take any action for you.
Under this Plan, proof of such authority will include (1) a completed, signed and approved Appoint a Personal Representative
form; (2) a notarized power of attorney for health care purposes; (3) a court-appointed conservator or guardian; or, (4) for a
Spouse under this Plan, the absence of a Revoke a Personal Representative form on file with the Privacy Officer.
This Plan will automatically recognize your legal Spouse as your Personal Representative and vice versa, without you
having to complete a form to Appoint a Personal Representative. However, you may request that the Plan not
automatically honor your legal Spouse as your Personal Representative by completing a form to Revoke a Personal
Representative (copy attached to this notice or also available from the Privacy Officer). If you wish to revoke your Spouse
as your Personal Representative, please complete the Revoke a Personal Representative form and return it to the
Privacy Officer and this will mean that this Plan will NOT automatically recognize your Spouse as your Personal
Representative and vice versa.
6
The recognition of your Spouse as your Personal Representative (and vice versa) is for the use and disclosure of PHI under
this Plan and is not intended to expand such designation beyond what is necessary for this Plan to comply with HIPAA
privacy regulations.
You may obtain a form to Appoint a Personal Representative or Revoke a Personal Representative by contacting the Privacy
Officer at their address listed on this Notice. The Plan retains discretion to deny access to your PHI to a Personal
Representative to provide protection to those vulnerable people who depend on others to exercise their rights under these
rules and who may be subject to abuse or neglect.
Because HIPAA regulations give adults certain rights and generally children age 18 and older are adults, if you have
dependent children age 18 and older covered under the Plan, and the child wants you, as the parent(s), to be able to access
their protected health information (PHI), that child will need to complete a form to Appoint a Personal Representative to
designate you (the employee/retiree) and/or your Spouse as their Personal Representatives.
The Plan will consider a parent, guardian, or other person acting in loco parentis as the Personal Representative of an
unemancipated minor (a child generally under age 18) unless the applicable law requires otherwise. In loco parentis may be
further defined by state law, but in general it refers to a person who has been treated as a parent by the child and who has
formed a meaningful parental relationship with the child for a substantial period of time. Spouses and unemancipated minors
may, however, request that the Plan restrict PHI that goes to family members as described above under the section titled
“Your Individual Privacy Rights.”
The Plan’s Duties
The Plan is required by law to maintain the privacy of your PHI and to provide you and your eligible dependents with Notice
of its legal duties and privacy practices. The Plan is required to comply with the terms of this Notice. However, the Plan
reserves the right to change its privacy practices and the terms of this Notice and to apply the changes to any PHI maintained
by the Plan. In addition, the Plan may not (and does not) use your genetic information that is PHI for underwriting purposes.
Notice Distribution: The Notice will be provided to each person when they initially enroll for benefits in the Plan (the
Notice is provided in the Plan’s Initial Enrollment material/packets). The Notice is also available on the Plan’s website:
www.sisc.kern.org
. The Notice will also be provided upon request. Once every three years the Plan will notify the
individuals then covered by the Plan where to obtain a copy of the Notice. This Plan will satisfy the requirements of the
HIPAA regulation by providing the Notice to the named insured (covered employee) of the Plan; however, you are
encouraged to share this Notice with other family members covered under the Plan.
Notice Revisions: If a privacy practice of this Plan is changed affecting this Notice, a revised version of this Notice will be
provided to you and all participants covered by the Plan at the time of the change. Any revised version of the Notice will be
distributed within 60 days of the effective date of a material change to the uses and disclosures of PHI, your individual rights,
the duties of the Plan or other privacy practices stated in this Notice. Material changes are changes to the uses and
disclosures of PHI, an individual’s rights, the duties of the Plan or other privacy practices stated in the Privacy Notice.
Because our health plan posts its Notice on its web site, we will prominently post the revised Notice on that web site by the
effective date of the material change to the Notice. We will also provide the revised notice, or information about the material
change and how to obtain the revised Notice, in our next annual mailing to individuals covered by the Plan.
Disclosing Only the Minimum Necessary Protected Health Information
When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not
to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use,
disclosure or request, taking into consideration practical and technological limitations. However, the minimum necessary
standard will not apply in the following situations:
• Disclosures to or requests by a health care provider for treatment,
• Uses or disclosures made to you,
• Disclosures made to the Secretary of the U.S. Department of Health and Human Services in accordance with their
enforcement activities under HIPAA,
• Uses of disclosures required by law, and
• Uses of disclosures required for the Plan’s compliance with the HIPAA privacy regulations.
This Notice does not apply to information that has been de-identified. De-identified information is information that does not
identify you and there is no reasonable basis to believe that the information can be used to identify you.
7
As described in the amended Plan document, the Plan may share PHI with the Plan Sponsor for limited administrative
purposes, such as determining claims and appeals, performing quality assurance functions and auditing and monitoring the
Plan. The Plan shares the minimum information necessary to accomplish these purposes.
In addition, the Plan may use or disclose “summary health information” to the Plan Sponsor for obtaining premium bids or
modifying, amending or terminating the group health Plan. Summary health information means information that
summarizes claims history, claims expenses or type of claims experienced by individuals for whom the Plan Sponsor has
provided health benefits under a group health plan. Identifying information will be deleted from summary health
information, in accordance with HIPAA.
Your Right to File a Complaint
If you believe that your privacy rights have been violated, you may file a complaint with the Plan in care of the Plan’s
Privacy Officer, at the address listed on the first page of this Notice. Neither your employer nor the Plan will retaliate
against you for filing a complaint.
You may also file a complaint (within 180 days of the date you know or should have known about an act or omission) with
the Secretary of the U.S. Department of Health and Human Services by contacting their nearest office as listed in your
telephone directory or at this website (http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html
) or this website:
http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html or contact the Privacy Officer for more information about how
to file a complaint.
If You Need More Information
If you have any questions regarding this Notice or the subjects addressed in it, you may contact the Plan’s Privacy Officer at
the address listed on the first page of this Notice.
8
Self-Insured Schools of California (SISC)
Form to Revoke a Personal Representative
Complete the following chart to indicate the name of the Personal Representative to be revoked:
Plan Participant
Person to be Revoked as my
Personal Representative
Name (print):
Address
(City, State, Zip):
Phone:
( ) ( )
I, __________________________________________________________ (Name of Participant or Beneficiary)
hereby revoke __________________________________________________ (Name of Personal Representative)
□ to act on my behalf,
□ to act on behalf of my dependent child(ren), named:
__________________________________________________________________________________________,
in receiving any protected health information (PHI) that is (or would be) provided to a personal representative,
including any individual rights regarding PHI under HIPAA, effective __________________________________,
20____.
I understand that PHI has or may already have been disclosed to the above named Personal Representative prior
to the effective date of this form.
____________________________________ ________________________
Participant or Beneficiary’s Signature Date
Return this form to the SISC Privacy Officer (the Coordinator Health Benefits) at:
Self-Insured Schools of California (SISC)
2000 “K” Street P.O. Box 1847 - Bakersfield, CA 93303-1847
Phone: 661-636-4410
9
Annual Notice: Women’s Health and Cancer Rights Act (WHCRA)
Your group health plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides
benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry
between the breasts, prostheses, and complications resulting from a mastectomy (including
lymphedema).
For more information call the Customer Service phone number on your ID card or the SISC Benefits
department at 661-636-4410.
Where to Find a HIPAA Privacy Notice for Our Group Health Plan
HIPAA Privacy pertains to the following group health plan benefits sponsored by the Self-Insured
Schools of California (SISC):
• medical PPO plan options including utilization management, prescription benefit management
(PBM) and medical plan claims administration services,
• telemedicine program with MD live,
• self-funded dental PPO plan options,
• self-funded vision PPO plan options,
• Wellness program,
• Medicare Supplement program,
• COBRA administration,
• Health Flexible Spending Account (FSA) administration
You are provided with a complete HIPAA Privacy Notice when you enroll for these benefits. You can
obtain another copy of the plan's HIPAA Privacy Notice by going to the SISC website at
www.sisc.kern.org or you can write or call the SISC Benefits Department at P. O. Box 1847 Bakersfield,
CA 93303-1847.
HIPAA Privacy Notices that pertain to the insured medical plan benefits can be obtained by contacting
the insurance companies at the Customer Service phone number on your ID card.
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