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.